1
|
Gondolesi GE. History of clinical intestinal transplantation. Hum Immunol 2024; 85:110788. [PMID: 38519405 DOI: 10.1016/j.humimm.2024.110788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/27/2024] [Accepted: 03/11/2024] [Indexed: 03/24/2024]
Abstract
The intestines have been considered the "forbidden organ" for years, and intestinal failure became the last organ failure recognized as such in the medical field. The impossibility of providing adequate nutritional support, turned these patients into recipients of just palliative comfort. In the 1960's, parenteral nutrition appeared as the most reasonable replacement therapy, but the initial success obtained with clinical kidney, heart, liver, lung and pancreas transplantation served as background to explore intestinal transplantation. The first clinical report of an isolated intestinal transplant was done by Richard Lillihei in 1967; in 1983, Thomas Starzl, performed the first multi visceral transplant, and in 1990, David Grant performed the first combined liver-intestinal transplant in an adult recipient in Canada. Since then, advances in immunosuppressive therapies and surgical innovations have allowed not only a continuous increase in indications, but also a worldwide application of all procedures, bringing clinical intestinal transplantation to reality. In this historical account, the most important contributions have been summarized, thus describing the steady progress, expansion and novelties developed over the last 56 years, since the first attempt. Clinical intestinal transplantation remains a complex and evolving field; ongoing research and technological advancements will continue shaping its future.
Collapse
Affiliation(s)
- Gabriel E Gondolesi
- Chief of General Surgery, Chief of Liver, Intestine and Pancreas Transplant, Hospital Universitario, Fundación Favaloro, Buenos Aires, Argentina.
| |
Collapse
|
2
|
Sato N, Marubashi S. How is transfusion-associated graft-versus-host disease similar to, yet different from, organ transplantation-associated graft-versus-host disease? Transfus Apher Sci 2022; 61:103406. [DOI: 10.1016/j.transci.2022.103406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
3
|
Twenty Years of Gut Transplantation for Chronic Intestinal Pseudo-obstruction: Technical Innovation, Long-term Outcome, Quality of Life, and Disease Recurrence. Ann Surg 2021; 273:325-333. [PMID: 31274659 DOI: 10.1097/sla.0000000000003265] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To define long-term outcome, predictors of survival, and risk of disease recurrence after gut transplantation (GT) in patients with chronic intestinal pseudo-obstruction (CIPO). BACKGROUND GT has been increasingly used to rescue patients with CIPO with end-stage disease and home parenteral nutrition (HPN)-associated complications. However, long-term outcome including quality of life and risk of disease recurrence has yet to be fully defined. METHODS Fifty-five patients with CIPO, 23 (42%) children and 32 (58%) adults, underwent GT and were prospectively studied. All patients suffered gut failure, received HPN, and experienced life-threatening complications. The 55 patients received 62 allografts; 43 (67%) liver-free and 19 (33%) liver-contained with 7 (13%) retransplants. Hindgut reconstruction was adopted in 1993 and preservation of native spleen was introduced in 1999. Immunosuppression was tacrolimus-based with antilymphocyte recipient pretreatment in 41 (75%). RESULTS Patient survival was 89% at 1 year and 69% at 5 years with respective graft survival of 87% and 56%. Retransplantation was successful in 86%. Adults experienced better patient (P = 0.23) and graft (P = 0.08) survival with lower incidence of post-transplant lymphoproliferative disorder (P = 0.09) and graft versus host disease (P = 0.002). Antilymphocyte pretreatment improved overall patient (P = 0.005) and graft (P = 0.069) survival. The initially restored nutritional autonomy was sustainable in 23 (70%) of 33 long-term survivors with improved quality of life. The remaining 10 recipients required reinstitution of HPN due to allograft enterectomy (n = 3) or gut dysfunction (n = 7). Disease recurrence was highly suspected in 4 (7%) recipients. CONCLUSIONS GT is life-saving for patients with end-stage CIPO and HPN-associated complications. Long-term survival is achievable with better quality of life and low risk of disease recurrence.
Collapse
|
4
|
|
5
|
Management of Five Hundred Patients With Gut Failure at a Single Center: Surgical Innovation Versus Transplantation With a Novel Predictive Model. Ann Surg 2020; 270:656-674. [PMID: 31436550 DOI: 10.1097/sla.0000000000003523] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE(S) To define the evolving role of integrative surgical management including transplantation for patients gut failure (GF). METHODS A total of 500 patients with total parenteral nutrition-dependent catastrophic and chronic GF were referred for surgical intervention particularly transplantation and comprised the study population. With a mean age of 45 ± 17 years, 477 (95%) were adults and 23 (5%) were children. Management strategy was guided by clinical status, splanchnic organ functions, anatomy of residual gut, and cause of GF. Surgery was performed in 462 (92%) patients and 38 (8%) continued medical treatment. Definitive autologous gut reconstruction (AGR) was achievable in 378 (82%), primary transplant in 42 (9%), and AGR followed by transplant in 42 (9%). The 84 transplant recipients received 94 allografts; 67 (71%) liver-free and 27 (29%) liver-contained. The 420 AGR patients received a total of 790 reconstructive and remodeling procedures including primary reconstruction, interposition alimentary-conduits, intestinal/colonic lengthening, and reductive/decompressive surgery. Glucagon-like peptide-2 was used in 17 patients. RESULTS Overall patient survival was 86% at 1-year and 68% at 5-years with restored nutritional autonomy (RNA) in 63% and 78%, respectively. Surgery achieved a 5-year survival of 70% with 82% RNA. AGR achieved better long-term survival and transplantation better (P = 0.03) re-established nutritional autonomy. Both AGR and transplant were cost effective and quality of life better improved after AGR. A model to predict RNA after AGR was developed computing anatomy of reconstructed gut, total parenteral nutrition requirements, cause of GF, and serum bilirubin. CONCLUSIONS Surgical integration is an effective management strategy for GF. Further progress is foreseen with the herein-described novel techniques and established RNA predictive model.
Collapse
|
6
|
Abrol N, Jadlowiec CC, Taner T. Revisiting the liver’s role in transplant alloimmunity. World J Gastroenterol 2019; 25:3123-3135. [PMID: 31333306 PMCID: PMC6626728 DOI: 10.3748/wjg.v25.i25.3123] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/25/2019] [Accepted: 05/18/2019] [Indexed: 02/06/2023] Open
Abstract
The transplanted liver can modulate the recipient immune system to induce tolerance after transplantation. This phenomenon was observed nearly five decades ago. Subsequently, the liver’s role in multivisceral transplantation was recognized, as it has a protective role in preventing rejection of simultaneously transplanted solid organs such as kidney and heart. The liver has a unique architecture and is home to many cells involved in immunity and inflammation. After transplantation, these cells migrate from the liver into the recipient. Early studies identified chimerism as an important mechanism by which the liver modulates the human immune system. Recent studies on human T-cell subtypes, cytokine expression, and gene expression in the allograft have expanded our knowledge on the potential mechanisms underlying immunomodulation. In this article, we discuss the privileged state of liver transplantation compared to other solid organ transplantation, the liver allograft’s role in multivisceral transplantation, various cells in the liver involved in immune responses, and the potential mechanisms underlying immunomodulation of host alloresponses.
Collapse
Affiliation(s)
- Nitin Abrol
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Massyo Clinic, Rochester, MN 55905, United States
| | | | - Timucin Taner
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Massyo Clinic, Rochester, MN 55905, United States
| |
Collapse
|
7
|
Donor-specific antibody management in intestine transplantation: hope for improving the long-term durability of the intestine allograft? Curr Opin Organ Transplant 2019; 24:212-218. [DOI: 10.1097/mot.0000000000000619] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
8
|
Costa G, Parekh N, Osman M, Armanyous S, Fujiki M, Abu-Elmagd K. Composite and Multivisceral Transplantation: Nomenclature, Surgical Techniques, Current Practice, and Long-term Outcome. Surg Clin North Am 2018; 99:129-151. [PMID: 30471738 DOI: 10.1016/j.suc.2018.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The successful development of multivisceral and composite visceral transplantation is among the milestones in the recent history of human organ transplantation. All types of gastrointestinal transplantation have evolved to be the standard of care for patients with gut failure and complex abdominal pathologic conditions. The outcome has markedly improved over the last 3 decades owing to technical innovation, novel immunosuppression, and better postoperative care. Recent data documented significant improvement in the long-term therapeutic indices of all types of visceral transplantation close to that achieved with thoracic and solid abdominal organs.
Collapse
Affiliation(s)
- Guilherme Costa
- Center for Gut Rehabilitation and Transplantation, Cleveland Clinic, 9500 Euclid Avenue, Desk A100, Cleveland, OH 44195, USA
| | - Neha Parekh
- Center for Gut Rehabilitation and Transplantation, Cleveland Clinic, 9500 Euclid Avenue, Desk A100, Cleveland, OH 44195, USA
| | - Mohammed Osman
- Center for Gut Rehabilitation and Transplantation, Cleveland Clinic, 9500 Euclid Avenue, Desk A100, Cleveland, OH 44195, USA
| | - Sherif Armanyous
- Department of Nephrology, Cleveland Clinic, 9500 Euclid Avenue, Desk A100, Cleveland, OH 44195, USA
| | - Masato Fujiki
- Center for Gut Rehabilitation and Transplantation, Cleveland Clinic, 9500 Euclid Avenue, Desk A100, Cleveland, OH 44195, USA
| | - Kareem Abu-Elmagd
- Center for Gut Rehabilitation and Transplantation, Cleveland Clinic, 9500 Euclid Avenue, Desk A100, Cleveland, OH 44195, USA; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk A100, Cleveland, OH 44195, USA.
| |
Collapse
|
9
|
Nassar A, Quintini C, Costa G, Lennon E, Bottino R, Hatipoglu B, Hashimoto K, Fujiki M, Kandeel F, Walsh RM, Abu-Elmagd K. Total pancreaticoduodenectomy with autologous islet transplantation 14 years after liver-contained composite visceral transplantation. Am J Transplant 2018; 18:2068-2074. [PMID: 29673066 DOI: 10.1111/ajt.14880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/18/2018] [Accepted: 04/03/2018] [Indexed: 01/25/2023]
Abstract
Chronic pancreatitis (CP) is a severely disabling disorder with potential detrimental effects on quality of life, gut function, and glucose homeostasis. Disease progression often results in irreversible morphological and functional abnormalities with development of chronic pain, mechanical obstruction, and pancreatic insufficiency. Along with comprehensive medical management, the concept of total pancreatectomy and islet autotransplantation (TP-AIT) was introduced 40 years ago for patients with intractable pain and preserved beta-cell function. With anticipated technical difficulties, total excision of the inflamed-disfigured gland is expected to alleviate the incapacitating visceral pain and correct other associated abdominal pathology. With retrieval of sufficient islet-cell mass, the autologous transplant procedure has the potential to maintain an euglycemic state without exogenous insulin requirement. The reported herein case of CP-induced recalcitrant pain and foregut obstruction is exceptional because of the technical challenges in performing native pancreaticoduodenectomy in close proximity to the composite visceral allograft with complex vascular and gut reconstructions. Equally novel is transplanting the auto-islets in the liver-contained visceral allograft. Despite intravenous nutrition shortly after birth, liver transplantation at age 13, retransplantation with liver-contained visceral allograft at age 17 and TP-AIT at age 31, the 38-year-old recipient is currently pain free with full nutritional autonomy and normal glucose homeostasis.
Collapse
Affiliation(s)
- Ahmed Nassar
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Cristiano Quintini
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Guilherme Costa
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Elizabeth Lennon
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rita Bottino
- Institute of Cellular Therapeutics, Allegheny Health Network, Pittsburgh, PA, USA
| | - Betul Hatipoglu
- Department of Endocrinology, Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Koji Hashimoto
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Masato Fujiki
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Fouad Kandeel
- Department of Internal Medicine, City of Hope Health System, Los Angeles, CA, USA
| | - R Matthew Walsh
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kareem Abu-Elmagd
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
10
|
Wozniak LJ, Mauer TL, Venick RS, Said JW, Kao RL, Kempert P, Marcus EA, Hwang V, Cheng EY, Busuttil RW, McDiarmid SV, Farmer DG. Clinical characteristics and outcomes of PTLD following intestinal transplantation. Clin Transplant 2018; 32:e13313. [DOI: 10.1111/ctr.13313] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2018] [Indexed: 12/23/2022]
Affiliation(s)
- Laura J. Wozniak
- Pediatric Gastroenterology, Hepatology, and Nutrition; David Geffen School of Medicine at UCLA; Los Angeles CA USA
| | - Tian L. Mauer
- Division of Liver and Pancreas Transplantation; David Geffen School of Medicine at UCLA; Los Angeles CA USA
| | - Robert S. Venick
- Pediatric Gastroenterology, Hepatology, and Nutrition; David Geffen School of Medicine at UCLA; Los Angeles CA USA
- Division of Liver and Pancreas Transplantation; David Geffen School of Medicine at UCLA; Los Angeles CA USA
| | - Jonathan W. Said
- Department of Pathology and Laboratory Medicine; David Geffen School of Medicine at UCLA; Los Angeles CA USA
| | - Roy L. Kao
- Pediatric Hematology and Oncology; David Geffen School of Medicine at UCLA; Los Angeles CA USA
| | - Pamela Kempert
- Pediatric Hematology and Oncology; David Geffen School of Medicine at UCLA; Los Angeles CA USA
| | - Elizabeth A. Marcus
- Pediatric Gastroenterology, Hepatology, and Nutrition; David Geffen School of Medicine at UCLA; Los Angeles CA USA
- VA Greater Los Angeles Health Care System; Los Angeles CA USA
| | - Vilayphone Hwang
- Division of Liver and Pancreas Transplantation; David Geffen School of Medicine at UCLA; Los Angeles CA USA
| | - Elaine Y. Cheng
- Division of Liver and Pancreas Transplantation; David Geffen School of Medicine at UCLA; Los Angeles CA USA
| | - Ronald W. Busuttil
- Division of Liver and Pancreas Transplantation; David Geffen School of Medicine at UCLA; Los Angeles CA USA
| | - Sue V. McDiarmid
- Pediatric Gastroenterology, Hepatology, and Nutrition; David Geffen School of Medicine at UCLA; Los Angeles CA USA
- Division of Liver and Pancreas Transplantation; David Geffen School of Medicine at UCLA; Los Angeles CA USA
| | - Douglas G. Farmer
- Division of Liver and Pancreas Transplantation; David Geffen School of Medicine at UCLA; Los Angeles CA USA
| |
Collapse
|
11
|
Costa G, Parekh N, Osman M, Armanyous S, Fujiki M, Abu-Elmagd K. Composite and Multivisceral Transplantation: Nomenclature, Surgical Techniques, Current Practice, and Long-term Outcome. Gastroenterol Clin North Am 2018; 47:393-415. [PMID: 29735032 DOI: 10.1016/j.gtc.2018.01.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
The successful development of multivisceral and composite visceral transplantation is among the milestones in the recent history of human organ transplantation. All types of gastrointestinal transplantation have evolved to be the standard of care for patients with gut failure and complex abdominal pathologic conditions. The outcome has markedly improved over the last 3 decades owing to technical innovation, novel immunosuppression, and better postoperative care. Recent data documented significant improvement in the long-term therapeutic indices of all types of visceral transplantation close to that achieved with thoracic and solid abdominal organs.
Collapse
Affiliation(s)
- Guilherme Costa
- Center for Gut Rehabilitation and Transplantation, Cleveland Clinic, 9500 Euclid Avenue, Desk A100, Cleveland, OH 44195, USA
| | - Neha Parekh
- Center for Gut Rehabilitation and Transplantation, Cleveland Clinic, 9500 Euclid Avenue, Desk A100, Cleveland, OH 44195, USA
| | - Mohammed Osman
- Center for Gut Rehabilitation and Transplantation, Cleveland Clinic, 9500 Euclid Avenue, Desk A100, Cleveland, OH 44195, USA
| | - Sherif Armanyous
- Department of Nephrology, Cleveland Clinic, 9500 Euclid Avenue, Desk A100, Cleveland, OH 44195, USA
| | - Masato Fujiki
- Center for Gut Rehabilitation and Transplantation, Cleveland Clinic, 9500 Euclid Avenue, Desk A100, Cleveland, OH 44195, USA
| | - Kareem Abu-Elmagd
- Center for Gut Rehabilitation and Transplantation, Cleveland Clinic, 9500 Euclid Avenue, Desk A100, Cleveland, OH 44195, USA; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk A100, Cleveland, OH 44195, USA.
| |
Collapse
|
12
|
Rees MA, Amesur NB, Cruz RJ, Borhani AA, Abu-Elmagd KM, Costa G, Dasyam AK. Imaging of Intestinal and Multivisceral Transplantation. Radiographics 2018. [DOI: 10.1148/rg.2018170086] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Mitchell A. Rees
- From the Departments of Radiology (M.A.R., N.B.A., A.A.B., A.K.D.) and Surgery (R.J.C.), University of Pittsburgh Medical Center, 200 Lothrop St, Radiology Suite 200, East Wing E2051B, Pittsburgh, PA 15213; and Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio (K.M.A., G.C.)
| | - Nikhil B. Amesur
- From the Departments of Radiology (M.A.R., N.B.A., A.A.B., A.K.D.) and Surgery (R.J.C.), University of Pittsburgh Medical Center, 200 Lothrop St, Radiology Suite 200, East Wing E2051B, Pittsburgh, PA 15213; and Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio (K.M.A., G.C.)
| | - Ruy J. Cruz
- From the Departments of Radiology (M.A.R., N.B.A., A.A.B., A.K.D.) and Surgery (R.J.C.), University of Pittsburgh Medical Center, 200 Lothrop St, Radiology Suite 200, East Wing E2051B, Pittsburgh, PA 15213; and Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio (K.M.A., G.C.)
| | - Amir A. Borhani
- From the Departments of Radiology (M.A.R., N.B.A., A.A.B., A.K.D.) and Surgery (R.J.C.), University of Pittsburgh Medical Center, 200 Lothrop St, Radiology Suite 200, East Wing E2051B, Pittsburgh, PA 15213; and Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio (K.M.A., G.C.)
| | - Kareem M. Abu-Elmagd
- From the Departments of Radiology (M.A.R., N.B.A., A.A.B., A.K.D.) and Surgery (R.J.C.), University of Pittsburgh Medical Center, 200 Lothrop St, Radiology Suite 200, East Wing E2051B, Pittsburgh, PA 15213; and Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio (K.M.A., G.C.)
| | - Guilherme Costa
- From the Departments of Radiology (M.A.R., N.B.A., A.A.B., A.K.D.) and Surgery (R.J.C.), University of Pittsburgh Medical Center, 200 Lothrop St, Radiology Suite 200, East Wing E2051B, Pittsburgh, PA 15213; and Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio (K.M.A., G.C.)
| | - Anil K. Dasyam
- From the Departments of Radiology (M.A.R., N.B.A., A.A.B., A.K.D.) and Surgery (R.J.C.), University of Pittsburgh Medical Center, 200 Lothrop St, Radiology Suite 200, East Wing E2051B, Pittsburgh, PA 15213; and Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio (K.M.A., G.C.)
| |
Collapse
|
13
|
Garcia Aroz S, Tzvetanov I, Hetterman EA, Jeon H, Oberholzer J, Testa G, John E, Benedetti E. Long-term outcomes of living-related small intestinal transplantation in children: A single-center experience. Pediatr Transplant 2017; 21. [PMID: 28295952 DOI: 10.1111/petr.12910] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2016] [Indexed: 12/13/2022]
Abstract
Pediatric patients with irreversible intestinal failure present a significant challenge to meet the nutritional needs that promote growth. From 2002 to 2013, 13 living-related small intestinal transplantations were performed in 10 children, with a median age of 18 months. Grafts included isolated living-related intestinal transplantation (n=7), and living-related liver and small intestine (n=6). The immunosuppression protocol consisted of induction with thymoglobulin and maintenance therapy with tacrolimus and steroids. Seven of 10 children are currently alive with a functioning graft and good quality of life. Six of the seven children who are alive have a follow-up longer than 10 years. The average time to initiation of oral diet was 32 days (range, 13-202 days). The median day for ileostomy takedown was 77 (range, 18-224 days). Seven children are on an oral diet, and one of them is on supplements at night through a g-tube. We observed an improvement in growth during the first 3 years post-transplant and progressive weight gain throughout the first year post-transplantation. Growth catch-up and weight gain plateaued after these time periods. We concluded that living donor intestinal transplantation potentially offers a feasible, alternative strategy for long-term treatment of irreversible intestinal failure in children.
Collapse
Affiliation(s)
- Sandra Garcia Aroz
- Division of Transplantation, Department of Surgery, University of Illinois, Chicago, IL, USA
| | - Ivo Tzvetanov
- Division of Transplantation, Department of Surgery, University of Illinois, Chicago, IL, USA
| | | | - Hoonbae Jeon
- Division of Transplantation, Department of Surgery, University of Illinois, Chicago, IL, USA
| | - Jose Oberholzer
- Division of Transplantation, Department of Surgery, University of Illinois, Chicago, IL, USA
| | - Giuliano Testa
- Division of Transplantation, Department of Surgery, Baylor University, Houston, TX, USA
| | - Eunice John
- Division of Nephrology, Department of Pediatrics, University of Illinois, Chicago, IL, USA
| | - Enrico Benedetti
- Division of Transplantation, Department of Surgery, University of Illinois, Chicago, IL, USA
| |
Collapse
|
14
|
Abstract
PURPOSE OF REVIEW The purpose of this article is to review the existing literature on the current indications, surgical techniques, immunosuppressive therapy and outcomes following intestinal transplantation (ITx). RECENT FINDINGS Over recent years, ITx has become a more common operation with approximately 2500 procedures carried out worldwide by 2014. It is reserved for patients with intestinal failure and who have developed complications of home parenteral nutrition or who have a high risk of dying from their underlying disease. Recent advances such as the improvement in survival rates, not only for isolated small bowel transplants but also following inclusion of a liver graft in combined liver-small bowel transplant, and the utility of citrulline as a noninvasive biomarker to appreciate acute rejection herald an exciting shift in the field of ITx. SUMMARY With advancements in immunosuppressive drugs, induction regimens, standardization of surgical techniques and improved postoperative care, survival is increasing. In due course, it will most likely become as good as remaining on home parenteral nutrition and as such could become a viable first-line option.
Collapse
|
15
|
Bharadwaj S, Tandon P, Gohel TD, Brown J, Steiger E, Kirby DF, Khanna A, Abu-Elmagd K. Current status of intestinal and multivisceral transplantation. Gastroenterol Rep (Oxf) 2017; 5:20-28. [PMID: 28130374 PMCID: PMC5444259 DOI: 10.1093/gastro/gow045] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Clinical-nutritional autonomy is the ultimate goal of patients with intestinal failure (IF). Traditionally, patients with IF have been relegated to lifelong parenteral nutrition (PN) once surgical and medical rehabilitation attempts at intestinal adaptation have failed. Over the past two decades, however, outcome improvements in intestinal transplantation have added another dimension to the therapeutic armamentarium in the field of gut rehabilitation. This has become possible through relentless efforts in the standardization of surgical techniques, advancements in immunosuppressive therapies and induction protocols and improvement in postoperative patient care. Four types of intestinal transplants include isolated small bowel transplant, liver-small bowel transplant, multivisceral transplant and modified multivisceral transplant. Current guidelines restrict intestinal transplantation to patients who have had significant complications from PN including liver failure and repeated infections. From an experimental stage to the currently established therapeutic modality for patients with advanced IF, outcome improvements have also been possible due to the introduction of tacrolimus in the early 1990s. Studies have shown that intestinal transplant is cost-effective within 1-3 years of graft survival compared with PN. Improved survival and quality of life as well as resumption of an oral diet should enable intestinal transplantation to be an important option for patients with IF in addition to continued rehabilitation. Future research should focus on detecting biomarkers of early rejection, enhanced immunosuppression protocols, improved postoperative care and early referral to transplant centers.
Collapse
Affiliation(s)
- Shishira Bharadwaj
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Parul Tandon
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Tushar D Gohel
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jill Brown
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ezra Steiger
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Donald F Kirby
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ajai Khanna
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kareem Abu-Elmagd
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| |
Collapse
|
16
|
Hashimoto K, Costa G, Khanna A, Fujiki M, Quintini C, Abu-Elmagd K. Recent Advances in Intestinal and Multivisceral Transplantation. Adv Surg 2016; 49:31-63. [PMID: 26299489 DOI: 10.1016/j.yasu.2015.04.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Koji Hashimoto
- Center for Gut Rehabilitation and Transplantation, Transplant Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Guilherme Costa
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15261, USA
| | - Ajai Khanna
- Center for Gut Rehabilitation and Transplantation, Transplant Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Masato Fujiki
- Center for Gut Rehabilitation and Transplantation, Transplant Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Cristiano Quintini
- Center for Gut Rehabilitation and Transplantation, Transplant Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Kareem Abu-Elmagd
- Center for Gut Rehabilitation and Transplantation, Transplant Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| |
Collapse
|
17
|
Abstract
Intestine transplantation has evolved into a feasible alternative for children with permanent intestinal failure and life-threatening complications related to total parenteral nutrition. Although the first transplantations were done nearly 40 years ago, long-term survival has only been achieved in the last decade. Nearly 700 intestinal transplantations have been performed internationally since 1985, with an overall patient survival of greater than 50%. Improvements in patient selection, medical management, and assessment and treatment for rejection and infection have contributed to the increased survival. This article will discuss current results and medical management strategies for this innovative type of transplantation for children with end-stage short gut syndrome.
Collapse
Affiliation(s)
- Beverly Kosmach Park
- Department of Transplant Surgery, Starzl Transplantation Institute, Children's Hospital of Pittsburgh, Pittsburgh, Pa., USA
| |
Collapse
|
18
|
Abstract
As technology introduces more advanced therapies, individuals have realized that quantity or length of life may not always be the ultimate goal in treating disease. The quality of life at times is as important as length of life. In this article, we review the literature regarding quality of life after intestinal transplantation. Published data on patient survival are briefly reviewed and the available studies investigating quality of life are examined. Few studies have been performed to date, but the limitations and implications of the available studies are summarized.
Collapse
Affiliation(s)
- Debra Sudan
- University of Nebraska Medical Center, Omaha, Neb., USA
| |
Collapse
|
19
|
von Websky MW, Kitamura K, Ludwig-Portugall I, Kurts C, von Laffert M, LeMaoult J, Carosella ED, Abu-Elmagd K, Kalff JC, Schäfer N. Recombinant HLA-G as Tolerogenic Immunomodulant in Experimental Small Bowel Transplantation. PLoS One 2016; 11:e0158907. [PMID: 27404095 PMCID: PMC4942037 DOI: 10.1371/journal.pone.0158907] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 06/23/2016] [Indexed: 11/18/2022] Open
Abstract
The non-classical MHC I paralogue HLA-G is expressed by cytotrophoblast cells and implicated with fetomaternal tolerance by downregulating the maternal adaptive and innate immune response against the fetus. HLA-G expression correlates with favorable graft outcome in humans and recently promising immunosuppressive effects of therapeutic HLA-G in experimental transplantation (skin allograft acceptance) were shown. Consequently, we examined this novel therapeutic approach in solid organ transplantation. In this study, therapeutic recombinant HLA-G5 was evaluated for the first time in a solid organ model of acute rejection (ACR) after orthotopic intestinal transplantation (ITX). Allogenic ITX was performed in rats (Brown Norway to Lewis) with and without HLA-G treatment. It was found that HLA-G treatment significantly reduced histologically proven ACR at both an early and late postoperative timepoint (POD 4/7), concomitant to a functionally preserved graft contractility at POD 7. Interestingly, graft infiltration by myeloperoxidase+ cells was significantly reduced at POD7 by HLA-G treatment. Moreover, HLA-G treatment showed an effect on the allogenic T-cell immune response as assessed by flow cytometry: The influx of recipient-derived CD8+ T-cells into the graft mesenteric lymphnodes at POD7 was significantly reduced while CD4+ populations were not affected. As a potential mechanism of action, an induction of T-reg populations in the mesenteric lymphnodes was postulated, but flow cytometric analysis of classical CD4+/CD25+/FoxP3+Treg-cells showed no significant alteration by HLA-G treatment. The novel therapeutic approach using recombinant HLA-G5 reported herein demonstrates a significant immunosuppressive effect in this model of allogenic experimental intestinal transplantation. This effect may be mediated via inhibition of recipient-derived CD8+ T-cell populations either directly or by induction of non-classical Treg populations.
Collapse
Affiliation(s)
| | - Koji Kitamura
- Department of Surgery, University Hospital of Bonn, Bonn, Germany
- Department of Hepatobiliary Pancreatic Surgery and Transplantation, Kyoto University Hospital, Kyoto, Japan
| | | | - Christian Kurts
- Institute for Experimental Immunology, University of Bonn, Germany
| | | | - Joel LeMaoult
- CEA, iMETI, Research Division in Hematology and Immunology, Saint-Louis Hospital, Paris, France
| | - Edgardo D. Carosella
- CEA, iMETI, Research Division in Hematology and Immunology, Saint-Louis Hospital, Paris, France
| | - Kareem Abu-Elmagd
- Transplant Center, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Joerg C. Kalff
- Department of Surgery, University Hospital of Bonn, Bonn, Germany
| | - Nico Schäfer
- Department of Surgery, University Hospital of Bonn, Bonn, Germany
- * E-mail:
| |
Collapse
|
20
|
Abstract
Despite recent therapeutic advances, patients with Crohn's disease (CD) continue to experience high recurrence with cumulative structural damage and ultimate loss of nutritional autonomy. With short bowel syndrome, strictures, and enteric fistulae being the underlying pathology, CD is the second common indication for home parenteral nutrition (HPN). With development of intestinal failure, nutritional management including HPN is required as a rescue therapy. Unfortunately, some patients do not escape the HPN-associated complications. Therefore, the concept of gut rehabilitation has evolved as part of the algorithmic management of these patients, with transplantation being the ultimate life-saving therapy. With type 2 intestinal failure, comprehensive rehabilitative measures including nutritional care, pharmacologic manipulation, autologous reconstruction, and bowel lengthening is often successful, particularly in patients with quiescent disease. With type 3 intestinal failure, transplantation is the only life-saving treatment for patients with HPN failure and intractable disease. With CD being the second common indication for transplantation in adults, survival outcome continues to improve because of surgical innovation, novel immunosuppression, and better postoperative care. Despite being a rescue therapy, the procedure has achieved survival rates similar to other solid organs, and comparable to those who continue to receive HPN therapy. With similar technical, immunologic, and infectious complications, survival is similar in the CD and non-CD recipients. Full nutritional autonomy is achievable in most survivors with better quality of life and long-term cost-effectiveness. CD recurrence is rare with no impact on graft function. Further progress is anticipated with new insights into the pathogenesis of CD and mechanisms of transplant tolerance.
Collapse
|
21
|
Flynn B, Park BK, Bond G, McGhee W, Mazariegos G, Sindhi R, Reyes J, Abu-Elmagd K. Immunosuppressant Strategies for Intestinal Transplantation: A Review of a Tolerogenic Regimen. Prog Transplant 2016; 15:60-4. [PMID: 15839373 DOI: 10.1177/152692480501500110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intestinal, combined liver-intestinal, and multivisceral transplantation are now considered the standard of care for children and adults with permanent intestinal failure. Early attempts at intestinal transplantation were discouraging because of the high incidence of technical complications, rejection, and infection. Advances in the field of transplantation, including the introduction of tacrolimus, improved surgical techniques, and improvements in postoperative care, have led to a renewed interest in intestinal transplantation since 1990. The most significant achievement, however, has been the effective control of rejection and life-threatening infections. This article focuses on the experience to date of innovative strategies that induce lymphocyte depletion and reduction in the incidence of rejection. In this setting, low-maintenance immunosuppression is clinically achievable with an acceptable rate of allograft rejection. Subsequently, the long-term complications of immunosuppression are significantly reduced with achievement of better long-term survival, and an overall improvement in the quality of life.
Collapse
Affiliation(s)
- Bridget Flynn
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Rege A, Sudan D. Intestinal transplantation. Best Pract Res Clin Gastroenterol 2016; 30:319-35. [PMID: 27086894 DOI: 10.1016/j.bpg.2016.02.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 02/08/2016] [Accepted: 02/11/2016] [Indexed: 01/31/2023]
Abstract
Intestinal transplantation has now emerged as a lifesaving therapeutic option and standard of care for patients with irreversible intestinal failure. Improvement in survival over the years has justified expansion of the indications for intestinal transplantation beyond the original indications approved by Center for Medicare and Medicaid services. Management of patients with intestinal failure is complex and requires a multidisciplinary approach to accurately select candidates who would benefit from rehabilitation versus transplantation. Significant strides have been made in patient and graft survival with several advancements in the perioperative management through timely referral, improved patient selection, refinement in the surgical techniques and better understanding of the immunopathology of intestinal transplantation. The therapeutic efficacy of the procedure is well evident from continuous improvements in functional status, quality of life and cost-effectiveness of the procedure. This current review summarizes various aspects including current practices and evidence based recommendations of intestinal transplantation.
Collapse
Affiliation(s)
- Aparna Rege
- Department of Surgery, Division of Abdominal Transplantation, Duke University Medical Center, Durham, NC, USA.
| | - Debra Sudan
- Department of Surgery, Division of Abdominal Transplantation, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
23
|
Imaging findings in children with proliferative disorders following multivisceral transplantation. Pediatr Radiol 2015; 45:1138-45. [PMID: 25796382 DOI: 10.1007/s00247-015-3303-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 01/08/2015] [Accepted: 02/04/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND Multivisceral transplantation represents an important treatment option for children with intestinal failure. The attendant immunosuppression can lead to a spectrum of cellular proliferations including benign and malignant smooth muscle tumors and lymphoproliferative disorders, many related to cellular dysregulation from Epstein-Barr virus infection. OBJECTIVE The purpose of this study is to investigate the rates of post-transplantation proliferative disorders among children with multivisceral transplantation and to characterize the imaging and pathological features of these disorders. MATERIALS AND METHODS We identified all consecutive children who underwent multivisceral transplant from August 2004 to October 2011 with at least 27 months of clinical and imaging follow-up. We reviewed medical records to determine the underlying causes of the multivisceral transplant, age at transplantation, onset of neoplasm development, and outcome. Two pediatric radiologists reviewed all imaging studies independently and diagnosis of disease was made by consensus interpretation. Pathological specimens were reviewed for histopathological findings of post-transplantation neoplasm in this pediatric patient population. RESULTS The study population consisted of 14 consecutive pediatric patients (7 boys and 7 girls; mean age 26 months, range 4-113 months). Of these 14 children, 4 (29%) developed histologically confirmed post-transplant neoplasms at a mean time of 2.4 years after multivisceral transplantation. Types of neoplasms included post-transplant lymphoproliferative disorder (PTLD) in three (21%) and Epstein-Barr-virus-associated smooth muscle tumor in two (14%). (One child developed both neoplasms following transplantation). Both children with smooth muscle tumor associated with Epstein-Barr virus presented with characteristic hypointense solid masses with peripheral rim enhancement on cross-sectional imaging studies. The mortality rate of children who developed post-transplant neoplasms was higher than that of those who did not develop post-transplant neoplasm (50% vs. 10%, P = 0.17), suggesting a possible risk factor for death. CONCLUSION Post-transplant neoplasm in children with multivisceral transplantation occurs with high frequency, often presents as Epstein-Barr-virus-associated smooth muscle tumor showing characteristic peripheral rim enhancement on cross-sectional imaging studies.
Collapse
|
24
|
Abu-Elmagd K. The concept of gut rehabilitation and the future of visceral transplantation. Nat Rev Gastroenterol Hepatol 2015; 12:108-20. [PMID: 25601664 DOI: 10.1038/nrgastro.2014.216] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In the 1990s, the introduction of visceral transplantation fuelled interest in other innovative therapeutic modalities for gut rehabilitation. Ethanol lock and omega-3 lipid formulations were introduced to reduce the risks associated with total parenteral nutrition (TPN). Autologous surgical reconstruction and bowel lengthening have been increasingly utilized for patients with complex abdominal pathology and short-bowel syndrome. Glucagon-like peptide 2 analogue, along with growth hormone, are available to enhance gut adaptation and achieve nutritional autonomy. Intestinal transplantation continues to be limited to a rescue therapy for patients with TPN failure. Nonetheless, survival outcomes have substantially improved with advances in surgical techniques, immunosuppressive strategies and postoperative management. Furthermore, both nutritional autonomy and quality of life can be restored for more than two decades in most survivors, with social support and inclusion of the liver being favourable predictors of long-term outcome. One of the current challenges is the discovery of biomarkers to diagnose early rejection and further improve liver-free allograft survival. Currently, chronic rejection with persistence of preformed and development of de novo donor-specific antibodies is a major barrier to long-term graft function; this issue might be overcome with innovative immunological and tolerogenic strategies. This Review discusses advances in the field of gut rehabilitation, including intestinal transplantation, and highlights future challenges. With the growing interest in individualized medicine and the value of health care, a novel management algorithm is proposed to optimize patient care through an integrated multidisciplinary team approach.
Collapse
Affiliation(s)
- Kareem Abu-Elmagd
- Transplant Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| |
Collapse
|
25
|
Kubal CA, Mangus RS, Tector AJ. Intestine and multivisceral transplantation: current status and future directions. Curr Gastroenterol Rep 2015; 17:427. [PMID: 25613179 DOI: 10.1007/s11894-014-0427-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Intestinal failure and associated parenteral nutrition-induced liver failure cause significant morbidity, mortality, and health care burden. Intestine transplantation is now considered to be the standard of care in patients with intestinal failure who fail intestinal rehabilitation. Intestinal failure-associated liver disease is an important sequela of intestinal failure, caused by parenteral lipids, requiring simultaneous liver-intestine transplant. Lipid minimization and, in recent years, the emergence of fish oil-based lipid emulsions have been shown to reverse parenteral nutrition-associated hyperbilirubinemia, but not fibrosis. Significant progress in surgical techniques and immunosuppression has led to improved outcomes after intestine transplantation. Intestine in varying combination with liver, stomach, and pancreas, also referred to as multivisceral transplantation, is performed for patients with intestinal failure along with liver disease, surgical abdominal catastrophes, neuroendocrine and slow-growing tumors, and complete portomesenteric thrombosis with cirrhosis of the liver. Although acute and chronic rejection are major problems, long-term survivors have excellent quality of life and remain free of parenteral nutrition.
Collapse
Affiliation(s)
- Chandrashekhar A Kubal
- Transplant Division, Department of Surgery, Indiana University School of Medicine, 550 N University Blvd, Room 4601, Indianapolis, IN, 46202-5250, USA,
| | | | | |
Collapse
|
26
|
Grant D, Abu-Elmagd K, Mazariegos G, Vianna R, Langnas A, Mangus R, Farmer DG, Lacaille F, Iyer K, Fishbein T. Intestinal transplant registry report: global activity and trends. Am J Transplant 2015; 15:210-9. [PMID: 25438622 DOI: 10.1111/ajt.12979] [Citation(s) in RCA: 282] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 07/16/2014] [Accepted: 08/12/2014] [Indexed: 01/25/2023]
Abstract
The Registry has gathered information on intestine transplantation (IT) since 1985. During this time, individual centers have reported progress but small case volumes potentially limit the generalizability of this information. The present study was undertaken to examine recent global IT activity. Activity was assessed with descriptive statistics, Kaplan-Meier survival curves and a multiple variable analysis. Eighty-two programs reported 2887 transplants in 2699 patients. Regional practices and outcomes are now similar worldwide. Current actuarial patient survival rates are 76%, 56% and 43% at 1, 5 and 10 years, respectively. Rates of graft loss beyond 1 year have not improved. Grafts that included a colon segment had better function. Waiting at home for IT, the use of induction immune-suppression therapy, inclusion of a liver component and maintenance therapy with rapamycin were associated with better graft survival. Outcomes of IT have modestly improved over the past decade. Case volumes have recently declined. Identifying the root reasons for late graft loss is difficult due to the low case volumes at most centers. The high participation rate in the Registry provides unique opportunities to study these issues.
Collapse
Affiliation(s)
- D Grant
- Department of Surgery, University Health Network, Toronto, Canada
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Combined Surgical and Interventional Radiologic Management Strategies in Patients with Arterial Pseudo-Aneurysms After Multivisceral Transplantation. Transplantation 2014; 97:235-44. [DOI: 10.1097/tp.0b013e3182a9029a] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
28
|
Nikeghbalian S, Mehdi SH, Aliakbarian M, Kazemi K, Shamsaeefar A, Bahreini A, Mansoorian MR, Malekhosseini SA. Multivisceral and small bowel transplantation at shiraz organ transplant center. Int J Organ Transplant Med 2014; 5:59-65. [PMID: 25013680 PMCID: PMC4089340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Multivisceral transplantations were initially done in animal models to understand the immunological effects. Later on, in human beings, it has been considered a salvage procedure for unresectable complex abdominal malignancies. With advancement in surgical techniques, availability of better immunosuppressive drugs, and development of better post-operative management protocols, outcomes have been improved after these complex surgical procedures. OBJECTIVE To analyze and report results of multivisceral, modified multivisceral, and small bowel transplantations done at Shiraz Organ Transplant Center, Shiraz, southern Iran. METHODS Medical records of all patients who underwent multivisceral, modified multivisceral, and small bowel transplants were retrospectively analyzed. RESULTS There were 18 patients. The most common indications for the procedure in our series were unresectable carcinoma of pancreas followed by short bowel syndrome. 10 patients were alive after a median follow-up of 8.7 (range: 3-32) months. The remaining 8 patients died post-operatively, mostly from septicemia. CONCLUSION Multivisceral and small bowel transplantations are promising treatments for complex abdominal pathologies.
Collapse
Affiliation(s)
- S. Nikeghbalian
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran,,Correspondence: Mohsen Aliakbarian, MD, Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Nemazee Hospital, Zand Blvd, Shiraz, Iran, Tel: +98-711-647-4308, Fax: +98-711-647-4307, E-mail:
| | - S. H. Mehdi
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran,
| | - M. Aliakbarian
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran,,Surgical Oncology Research Center, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - K. Kazemi
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran,
| | - A. Shamsaeefar
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran,
| | - A. Bahreini
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran,
| | - M. R. Mansoorian
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran,
| | - S. A. Malekhosseini
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran,
| |
Collapse
|
29
|
Jackson K, Ruppert K, Shapiro R. Post-transplant lymphoproliferative disorder after pancreas transplantation: a United Network for Organ Sharing database analysis. Clin Transplant 2013; 27:888-94. [DOI: 10.1111/ctr.12252] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2013] [Indexed: 11/29/2022]
Affiliation(s)
- K. Jackson
- University of Pittsburgh School of Medicine; Pittsburgh PA USA
| | - K. Ruppert
- Department of Epidemiology; University of Pittsburgh School of Public Health; Pittsburgh PA USA
| | - R. Shapiro
- Division of Transplantation Surgery; Department of Surgery; Thomas E. Starzl Transplantation Institute; University of Pittsburgh; Pittsburgh PA USA
| |
Collapse
|
30
|
Histologic analysis of chronic rejection in small bowel transplantation: mucosal and vascular alterations. Transplantation 2013; 95:378-82. [PMID: 23238535 DOI: 10.1097/tp.0b013e318270f370] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Chronic rejection is a significant barrier to small bowel allograft survival. Although chronic rejection primarily involves vessels of the submucosa, serosa, and mesentery, some mucosal alterations have been suggested to be correlative. METHODS We retrospectively investigated explanted small bowel allografts for clinical characteristics and histological alterations in the mucosa, submucosa, and serosa. RESULTS Crypt epithelial mucin loss, submucosal fibrosis, and length of time to explant were all statistically associated with chronic rejection. Medium-sized and large-sized vessels of the serosa and mesentery preferentially demonstrated histologic changes of chronic rejection. CONCLUSION These results further define chronic vascular rejection and the relationship between the mucosal changes and chronic rejection.
Collapse
|
31
|
Hawksworth JS, Rosen-Bronson S, Island E, Girlanda R, Guerra JF, Valdiconza C, Kishiyama K, Christensen KD, Kozlowski S, Kaufman S, Little C, Shetty K, Laurin J, Satoskar R, Kallakury B, Fishbein TM, Matsumoto CS. Successful isolated intestinal transplantation in sensitized recipients with the use of virtual crossmatching. Am J Transplant 2012; 12 Suppl 4:S33-42. [PMID: 22947089 DOI: 10.1111/j.1600-6143.2012.04238.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We evaluated virtual crossmatching (VXM) for organ allocation and immunologic risk reduction in sensitized isolated intestinal transplantation recipients. All isolated intestine transplants performed at our institution from 2008 to 2011 were included in this study. Allograft allocation in sensitized recipients was based on the results of a VXM, in which the donor-specific antibody (DSA) was prospectively evaluated with the use of single-antigen assays. A total of 42 isolated intestine transplants (13 pediatric and 29 adult) were performed during this time period, with a median follow-up of 20 months (6-40 months). A sensitized (PRA ≥ 20%) group (n = 15) was compared to a control (PRA < 20%) group (n = 27) to evaluate the efficacy of VXM. With the use of VXM, 80% (12/15) of the sensitized patients were transplanted with a negative or weakly positive flow-cytometry crossmatch and 86.7% (13/15) with zero or only low-titer (≤ 1:16) DSA. Outcomes were comparable between sensitized and control recipients, including 1-year freedom from rejection (53.3% and 66.7% respectively, p = 0.367), 1-year patient survival (73.3% and 88.9% respectively, p = 0.197) and 1-year graft survival (66.7% and 85.2% respectively, p = 0.167). In conclusion, a VXM strategy to optimize organ allocation enables sensitized patients to successfully undergo isolated intestinal transplantation with acceptable short-term outcomes.
Collapse
Affiliation(s)
- J S Hawksworth
- Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Abu-Elmagd KM, Wu G, Costa G, Lunz J, Martin L, Koritsky DA, Murase N, Irish W, Zeevi A. Preformed and de novo donor specific antibodies in visceral transplantation: long-term outcome with special reference to the liver. Am J Transplant 2012; 12:3047-60. [PMID: 22947059 DOI: 10.1111/j.1600-6143.2012.04237.x] [Citation(s) in RCA: 141] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Despite improvement in early outcome, rejection particularly chronic allograft enteropathy continues to be a major barrier to long-term visceral engraftment. The potential role of donor specific antibodies (DSA) was examined in 194 primary adult recipients. All underwent complement-dependent lymphocytotoxic crossmatch (CDC-XM) with pre- and posttransplant solid phase HLA-DSA assay in 156 (80%). Grafts were ABO-identical with random HLA-match. Liver was included in 71 (37%) allografts. Immunosuppression was tacrolimus-based with antilymphocyte recipient pretreatment in 150 (77%). CDC-XM was positive in 55 (28%). HLA-DSA was detectable before transplant in 49 (31%) recipients with 19 continuing to have circulating antibodies. Another 19 (18%) developed de novo DSA. Ninety percent of patients with preformed DSA harbored HLA Class-I whereas 74% of recipients with de novo antibodies had Class-II. Gender, age, ABO blood-type, cold ischemia, splenectomy and allograft type were significant DSA predictors. Preformed DSA significantly (p < 0.05) increased risk of acute rejection. Persistent and de novo HLA-DSA significantly (p < 0.001) increased risk of chronic rejection and associated graft loss. Inclusion of the liver was a significant predictor of better outcome (p = 0.004, HR = 0.347) with significant clearance of preformed antibodies (p = 0.04, OR = 56) and lower induction of de novo DSA (p = 0.07, OR = 24). Innovative multifaceted anti-DSA strategies are required to further improve long-term survival particularly of liver-free allografts.
Collapse
Affiliation(s)
- K M Abu-Elmagd
- Department of Surgery Department of Pathology, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Long-term survival, nutritional autonomy, and quality of life after intestinal and multivisceral transplantation. Ann Surg 2012; 256:494-508. [PMID: 22868368 DOI: 10.1097/sla.0b013e318265f310] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To assess long-term survival, graft function, and health-related quality of life (QOL) after visceral transplantation. BACKGROUND Despite continual improvement in early survival, the long-term therapeutic efficacy of visceral transplantation has yet to be defined. METHODS A prospective cross-sectional study was performed on 227 visceral allograft recipients who survived beyond the 5-year milestone. Clinical data were used to assess outcome including graft function and long-term survival predictors. The socioeconomic milestones and QOL measures were assessed by clinical evaluation, professional consultation, and validated QOL inventory. RESULTS Of 376 recipients, 227 survived beyond 5 years, with conditional survival of 75% at 10 years and 61% at 15 years. With a mean follow-up of 10 ± 4 years, 177 (92 adults, 85 children) are alive, with 118 (67%) recipients 18 years or older. Nonfunctional social support and noninclusion of the liver in the visceral allograft are the most significant survival risk factors. Nutritional autonomy was achievable in 160 (90%) survivors, with current serum albumin level of 3.7 ± 0.5 gm/dL and body mass index of 25 ± 6 kg/m(2). Despite coexistence or development of neuropsychiatric disorders, most survivors were reintegrated to society with self-sustained socioeconomic status. In parallel, most of the psychological, emotional, and social QOL measures significantly (P < 0.05) improved after transplantation. Current morbidities with potential impact on global health included dysmotility (59%), hypertension (37%), osteoporosis (22%), and diabetes (11%), with significantly (P < 0.05) higher incidence among adult recipients. CONCLUSIONS With new tactics to further improve long-term survival including social support measures, visceral transplantation has achieved excellent nutritional autonomy and good QOL.
Collapse
|
34
|
|
35
|
Association between donor-specific antibodies and acute rejection and resolution in small bowel and multivisceral transplantation. Transplantation 2011; 92:709-15. [PMID: 21804443 DOI: 10.1097/tp.0b013e318229f752] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Donor-specific antibodies (DSA) are associated with acute kidney graft rejection, but their role in small bowel/multivisceral allograft remains unclear. We carried out a prospective study to understand the impact of DSA in the setting of intestinal allograft rejection. METHODS Thirteen patients (15 grafts) were serially evaluated for DSA levels pre- and posttransplant. DSA was determined by Luminex and the results were interpreted as fluorescence intensity (FI), with FI more than 3000 considered positive. RESULTS The clinical rejection episodes in allografts were significantly associated with the presence of DSA (P=0.041).We obtained 291 biopsy samples from graft ileum and date-matched DSA assay reports. Sixty-three (21.65%) of the biopsies showed acute rejection. The appearance of DSA were preformed (n=5, anti-human leukocyte antigen class II=3, anti-class I and II=2), de novo (n=4, 15.25±4.72 days after transplantation, anti-class II=1, and anti-class I and II=3) and never (n=6). Among the 63 biopsies, 30(47.6%) had significant correlations with positive DSA (kappa=0.30, P<0.001) and manifested severe rejection grade (P=0.009). CONCLUSIONS In this cohort of small bowel/multivisceral transplantation patients, there was a high incidence of DSA. The presence of DSA should alert the clinical team of a higher risk of rejection, and reduction of the FI is clinically associated with resolution. Serial endoscopy guided biopsies combined with simultaneous DSA measurement in postintestinal transplantation follow-up is an effective means of screening for cellular and humoral-based forms of acute rejection.
Collapse
|
36
|
Five hundred intestinal and multivisceral transplantations at a single center: major advances with new challenges. Ann Surg 2011; 250:567-81. [PMID: 19730240 DOI: 10.1097/sla.0b013e3181b67725] [Citation(s) in RCA: 250] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the evolution of visceral transplantation in the milieu of surgical technical modifications, new immunosuppressive protocols, and other management strategies. SUMMARY BACKGROUND DATA With the clinical feasibility of intestinal and multivisceral transplantation in 1990, multifaceted innovative tactics were required to improve outcome and increase procedural practicality. METHODS Divided into 3 eras, 453 patients received 500 visceral transplants. The primary used immunosuppression was tacrolimus-steroid-only during Era I (5/90–5/94), adjunct induction with multiple drug therapy during Era II (1/95–6/01), and recipient pretreatment with tacrolimus monotherapy during Era III (7/01–11/08). During Era II/III, donor bone marrow was given (n = 79), intestine was ex vivo irradiated (n = 44), and Epstein-Barr-Virus (EBV)/cytomegalovirus (CMV) loads were monitored. RESULTS Actuarial patient survival was 85% at 1-year, 61% at 5-years, 42% at 10-years, and 35% at 15-years with respective graft survival of 80%, 50%, 33%, and 29%. With a 10% retransplantation rate, second/third graft survival was 69% at 1-year and 47% at 5-years. The best outcome was with intestine-liver allografts. Era III rabbit antithymocyte globulin or alemtuzumab pretreatment-based strategy was associated with significant (P < 0.0001) improvement in outcome with 1- and 5-year patient survival of 92% and 70%. CONCLUSION Survival has greatly improved over time as management strategies evolved. The current results clearly justify elevating the procedure level to that of other abdominal organs with the privilege to permanently reside in a respected place in the surgical armamentarium. Meanwhile, innovative tactics are still required to conquer long-term hazards of chronic rejection of liver-free allografts and infection of multivisceral recipients.
Collapse
|
37
|
Quantification of Intraepithelial Lymphocytes in Normal Pediatric Small Intestinal Allograft and Native Ilea. Transplant Proc 2011; 43:1831-5. [DOI: 10.1016/j.transproceed.2011.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 02/02/2011] [Indexed: 11/20/2022]
|
38
|
Papachristou GI, Abu-Elmagd KM, Bond G, Costa G, Mazariegos GV, Sanders MK, Slivka A. Pancreaticobiliary complications after composite visceral transplantation: incidence, risk, and management strategies. Gastrointest Endosc 2011; 73:1165-73. [PMID: 21481866 DOI: 10.1016/j.gie.2011.01.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2010] [Accepted: 01/10/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Combined liver/small-bowel (L/SB) and multivisceral (MV) transplantation has been increasingly used with significant improvement in outcome. OBJECTIVE To report our experience with pancreaticobiliary (PB) complications in this unique population. DESIGN AND SETTING Single-center cohort study using a prospectively completed database. PATIENTS AND INTERVENTIONS From May 1990 to November 2008, records of 271 consecutive patients who received 289 composite visceral grafts were retrospectively reviewed; 151 of the allografts were L/SB (52%) and the remaining 138 were MV. MAIN OUTCOME MEASUREMENTS Type, incidence, risk factors, clinical features, and management of PB complications. RESULTS PB complications were diagnosed in 44 patients with an incidence of 16%. Biliary complications developed in 20 patients (ampullary stenosis in 9, bile duct casts/stones in 6, and bile duct leaks in 5), pancreatic complications occurred in 19 patients (necrotizing pancreatitis in 7, edematous pancreatitis in 6, and pancreatic duct fistulae in 6), and combined biliary and pancreatic complications occurred in 5 patients. The risk of PB complications was significantly higher in MV graft recipients compared with L/SB recipients with a rate of 25% compared with 9%, respectively. ERCP was instrumental in the diagnosis and/or treatment of ampullary stenosis, bile duct casts and stones, bile duct leaks, and recurrent acute pancreatitis. Combined endoscopic and surgical intervention was required in most cases of pancreatic duct fistulae. Surgical intervention was performed in patients with pancreatic allograft necrosis and complex anastomotic biliary leaks. LIMITATIONS Single-center study. CONCLUSIONS PB complications are common after composite visceral transplantation. Awareness of these complications is important to the transplantation team to ensure early diagnosis and appropriate intervention in an attempt to minimize morbidity and mortality.
Collapse
Affiliation(s)
- Georgios I Papachristou
- Division of Gastroenterology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | | | | |
Collapse
|
39
|
Pretransplant predictors of survival after intestinal transplantation: analysis of a single-center experience of more than 100 transplants. Transplantation 2011; 90:1574-80. [PMID: 21107306 DOI: 10.1097/tp.0b013e31820000a1] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Outcomes after intestinal transplantation (ITx) have steadily improved. There are few studies that assess factors associated with these enhanced results. The purpose of this study was to examine peri-ITx variables and survival. METHODS A review of a prospectively maintained database was undertaken and included all patients undergoing ITx from 1991 to 2010. The study endpoints were patient and graft survival. Data collection included 44 variables. Survival was computed using Kaplan-Meier methods. Univariate analysis was conducted (log-rank test) with significance set at P less than or equal to 0.20. Multivariate analysis of significant variables was conducted using model reduction by backward elimination variable selection method with significance set at P less than 0.05. RESULTS Eighty-eight patients received 106 ITx. The majority of recipients were male, Latino, and children. The leading causes of intestinal and liver failure were gastroschisis and parenteral nutrition. Grafts transplanted were isolated intestine (24%), liver-intestine (62%), and multivisceral (14%). Overall 1- and 5-year patient and graft survival were 80% and 65%, and 74% and 64%, respectively. Significant univariate survival predictors were weight less than 20 kg, children, liver-inclusive allograft, panel reactive antibody less than 20%, absence of donor-specific antibody, negative crossmatch, warm ischemia time less than 60 min, absence of recipient splenectomy, interleukin-2 receptor antagonist induction, and era. Significant multivariate survival predictors were absence of donor-specific antibody, absence of recipient splenectomy, and liver-inclusive graft type. CONCLUSION This large, single-center ITx experience confirms a marked improvement in outcome over time. Several important factors were associated with survival, and these factors can potentially be adjusted before ITx. These findings should refocus future efforts on strategies to improve treatment and prevent graft loss.
Collapse
|
40
|
Nayyar NS, McGhee W, Martin D, Sindhi R, Soltys K, Bond G, Mazariegos GV. Intestinal transplantation in children: a review of immunotherapy regimens. Paediatr Drugs 2011; 13:149-59. [PMID: 21500869 PMCID: PMC7101554 DOI: 10.2165/11588530-000000000-00000] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
This review summarizes the outcomes and known adverse effects of current immunosuppression strategies in use in pediatric intestinal transplantation. Intestinal transplantation has evolved from an experimental therapy to a highly successful treatment for children with intestinal failure who have complications with total parenteral nutrition. Because of continued success with intestinal transplantation over the past decade, the focus of clinicians and researchers is shifting from short-term patient survival to optimizing long-term outcomes. Current 5-year patient and graft survival rates after intestinal transplantation are 58% and 40%, respectively, in the US; single centers have reported nearly 80% patient and 60% graft survival rates at 5 years. The immunosuppression strategy in intestinal transplantation includes a tacrolimus-based regimen, usually in conjunction with an antibody induction therapy such as rabbit-antithymocyte globulin, interleukin-2 receptor antagonists, or alemtuzumab. The use of these immunosuppressive regimens, along with improved medical and surgical care, has contributed significantly toward improved outcomes. Optimization of post-transplant immunosuppression strategies to reduce adverse effects while minimizing acute and chronic graft rejection is a strong clinical and research focus.
Collapse
Affiliation(s)
- Navdeep S. Nayyar
- Hillman Center for Pediatric Transplantation, Children’s Hospital of Pittsburgh of UPMC, One Children’s Hospital Drive, 4401 Penn Avenue, Faculty Pavilion, Floor 6, Pittsburgh, Pennsylvania 15224 USA
| | - William McGhee
- Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania USA ,Department of Pharmacy, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania USA
| | - Dolly Martin
- Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania USA
| | - Rakesh Sindhi
- Hillman Center for Pediatric Transplantation, Children’s Hospital of Pittsburgh of UPMC, One Children’s Hospital Drive, 4401 Penn Avenue, Faculty Pavilion, Floor 6, Pittsburgh, Pennsylvania 15224 USA ,Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania USA
| | - Kyle Soltys
- Hillman Center for Pediatric Transplantation, Children’s Hospital of Pittsburgh of UPMC, One Children’s Hospital Drive, 4401 Penn Avenue, Faculty Pavilion, Floor 6, Pittsburgh, Pennsylvania 15224 USA ,Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania USA
| | - Geoffrey Bond
- Hillman Center for Pediatric Transplantation, Children’s Hospital of Pittsburgh of UPMC, One Children’s Hospital Drive, 4401 Penn Avenue, Faculty Pavilion, Floor 6, Pittsburgh, Pennsylvania 15224 USA ,Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania USA
| | - George V. Mazariegos
- Hillman Center for Pediatric Transplantation, Children’s Hospital of Pittsburgh of UPMC, One Children’s Hospital Drive, 4401 Penn Avenue, Faculty Pavilion, Floor 6, Pittsburgh, Pennsylvania 15224 USA ,Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania USA
| |
Collapse
|
41
|
Gonzalez-Pinto I, Tzakis A, Tsai HL, Chang JW, Tryphonopoulos P, Nishida S, Island E, Selvaggi G, Tekin A, Moon J, Levi D, Ruiz P. Association Between Panel Reactive Antibodies and Acute Small Bowel Rejection: Analysis of a Series of 324 Intestinal Transplants. Transplant Proc 2010; 42:4269-71. [DOI: 10.1016/j.transproceed.2010.09.078] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Accepted: 09/20/2010] [Indexed: 11/15/2022]
|
42
|
Modified "liver-sparing" multivisceral transplant with preserved native spleen, pancreas, and duodenum: technique and long-term outcome. J Gastrointest Surg 2010; 14:1709-21. [PMID: 20844978 DOI: 10.1007/s11605-010-1317-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Accepted: 08/09/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Modification of the originally described multivisceral transplant operation was introduced at our institution 17 years ago. Donor liver was spared, and native spleen along with pancreaticoduodenal complex was preserved. METHODS Thirty-six modified multivisceral grafts that include stomach, duodenum, pancreas, and intestine were given to 30 adults and six children. Leading causes of intestinal failure were pseudo-obstruction and Gardner's syndrome. Native spleen was preserved in 24 (67%) recipients along with pancreaticoduodenal complex in 18 (50%). Immunosuppression was tacrolimus-based, and recipient preconditioning was utilized in 80% of patients. RESULTS Patient survival was 94% at 1 year and 75% at 5 years with graft survival of 91% and 51%; respectively. With mean follow-up of 51 ± 35 months, full nutritional autonomy was achieved in 89% of current survivors with no single example of disease recurrence. Preservation of native spleen was associated with increased survival and reduced risk of PTLD, life-threatening infections, and GVHD with no significant impact on graft loss due to rejection. Concomitant preservation of pancreaticoduodenal complex eliminated risks of biliary complications and glucose intolerance. CONCLUSION Modified multivisceral transplantation with and without preservation of native spleen, pancreas, and duodenum is a valid therapeutic option for patients with diffuse gastrointestinal disorders and preserved hepatic functions.
Collapse
|
43
|
Eid KR, Costa G, Bond GJ, Cruz RJ, Rubin E, Bielefeldt K, Koritsky D, Abu-Elmagd KM. An innovative sphincter preserving pull-through technique with en bloc colon and small bowel transplantation. Am J Transplant 2010; 10:1940-6. [PMID: 20636461 DOI: 10.1111/j.1600-6143.2010.03167.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
This report describes a new innovative pull-through technique of hindgut reconstruction with en bloc small bowel and colon transplantation in a Crohn's disease patient with irreversible intestinal failure. The approach was intersphincteric and the anastomosis was established between the allograft colon and the recipient anal verge with achievement of full nutritional autonomy and anal continence.
Collapse
Affiliation(s)
- K R Eid
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | | | | | | | | | | |
Collapse
|
44
|
Petrisli E, Chiereghin A, Gabrielli L, Zanfi C, Lauro A, Piccirilli G, Baccolini F, Altimari A, Bagni A, Cescon M, Pinna AD, Landini MP, Lazzarotto T. Early and late virological monitoring of cytomegalovirus, Epstein-Barr virus, and human herpes virus 6 infections in small bowel/multivisceral transplant recipients. Transplant Proc 2010; 42:74-8. [PMID: 20172284 DOI: 10.1016/j.transproceed.2009.12.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) and Epstein-Barr virus (EBV) are the major causes of graft failure and posttransplantation mortality among small bowel and multivisceral transplantations (SB/MVT). Little is known about human herpes virus 6 (HHV-6) infections in transplant recipients. STUDY PURPOSE The purposes of this study were to analyze the clinical relevance of CMV, EBV, and HHV-6 infections after small bowel transplantation and to establish whether routine monitoring for HHV-6 infection should be recommended for the prevention of severe complications in this population. METHODS Ten adult patients were monitored based on CMV, EBV, and HHV6 DNA quantifications in blood and biopsy tissue samples. Three patients were monitored for at least 5 months (early period) and 7 patients were monitored for 1 to 5 years after transplantation (late period). RESULTS In the early period, despite prophylaxis all 3 patients developed symptomatic CMV infections: 1 fever/diarrhea, 1 enteritis and rejection, as well as 1 fever and pneumonia. Only 1 patient developed EBV and HHV-6 infections. The average time of onset of CMV infection was 3 months after transplantation and only 24 days for HHV6 infection. In the late period, of the 7 SB/MVT recipients only 1 developed an EBV infection at 2 years after transplantation. No CMV or HHV-6 infections were identified in any patient. CONCLUSIONS CMV infection is a major cause of organ disease and rejection in the early period after transplantation. EBV infection in adult recipients must be considered also in the late period, particularly in association with severe immunosuppression. Because HHV-6 infection occurs earlier than CMV/EBV, it may serve as an indicator for more intense virological surveillance.
Collapse
Affiliation(s)
- E Petrisli
- St.Orsola Malpighi General Hospital, University of Bologna, Bologna, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Lymphoproliferative disorders and de novo malignancies in intestinal and multivisceral recipients: improved outcomes with new outlooks. Transplantation 2010; 88:926-34. [PMID: 19935465 DOI: 10.1097/tp.0b013e3181b7509c] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Early experience with intestinal and multivisceral transplantation was plagued with high risk of rejection and posttransplant lymphoproliferative disorders (PTLD). To improve outcome, innovative management and immunosuppressant strategies were sequentially evolved. METHODS With initiation of the program in 1990, serial monitoring of Epstein-Barr-Viral load was introduced in 1994 with adoption of preemptive antiviral therapy. In 1995, cyclophosphamide or daclizumab induction was added to the tacrolimus-steroid-based multiple drug immunosuppressions. Such a conventional approach was replaced in 2001 with a novel immunosuppressive protocol consisting of recipient pretreatment with a single dose of rabbit antithymocyte globulin or alemtuzumab and posttransplant tacrolimus monotherapy. RESULTS With a total of 395 consecutive primary recipients, de novo malignancy(s) developed in 61 (15%) patients, with PTLD in 52 (13%), and nonlymphoid cancer (NLC) in 13 (3.2%). Malignancy was donor driven in 3 (4.6%) recipients and associated with graft-versus-host disease in 7 (11.4%). Children were at a significantly higher risk (P<0.001) of PTLD, and adults were more vulnerable (P=0.01) to NLC. With multivariate analyses, type of immunosuppression, recipient age, splenectomy, and treatment of rejection were significant PTLD risk factors. CONCLUSIONS Despite pretransplant lymphoid depletion, preemptive antiviral therapy and minimization of posttransplant immunosuppression significantly reduced PTLD morbidity (P=0.0001) and mortality (P=0.001) with no impact on NLC. Patient survival was also improved (P=0.0001) with 91% at 1 year and 75% at 5 years.
Collapse
|
46
|
Yuan-Xin L, Ning L, You-Sheng L, Xiao-Dong N, Ming L, Jian W, Jie-Shou L. Preliminary Experience With Alemtuzumab Induction Therapy Combined With Maintenance Low-Dose Tacrolimus Monotherapy in Small-Bowel Transplantation in China. Transplant Proc 2010; 42:29-34. [DOI: 10.1016/j.transproceed.2009.12.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
47
|
|
48
|
Matarese LE, Dvorchik I, Costa G, Bond GJ, Koritsky DA, Ferraris RP, Touger-Decker R, O'Sullivan-Maillet JK, Abu-Elmagd KM. Pyridoxal-5'-phosphate deficiency after intestinal and multivisceral transplantation. Am J Clin Nutr 2009; 89:204-9. [PMID: 19056562 DOI: 10.3945/ajcn.2008.26898] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Successful intestinal transplantation is measured by the achievement of clinical nutritional autonomy (CNA). However, the ability of the graft to maintain normal micronutrient levels including vitamins has yet to be thoroughly evaluated. OBJECTIVE After an initial clinical observation of isolated cases of pyridoxal-5'-phosphate (PLP) deficiency, this prospective study was designed to address the incidence of, risk factors for, and management of PLP deficiency in adult intestinal transplant recipients. DESIGN Serum PLP and homocysteine concentrations were prospectively measured before and after transplantation at frequent intervals. RESULTS PLP deficiency occurred in 10% of candidates and in 96% of recipients within a median onset of 30 d (range: 4-118 d) after transplantation. Of this group, 41% were receiving parenteral nutrition (PN), 41% were receiving enteral feeding, and the remaining 18% had already achieved CNA. The overall cumulative risk was 24% at 15 d, 59% at 30 d, 79% at 45 d, and 90% at 90 d; none of the risk factors, including homocysteine concentrations, were significant. Nonetheless, the development of PLP deficiency during PN therapy was associated with a significant (P < 0.001) delay in the achievement of CNA. Despite development of severe deficiency in most cases, none of the subjects experienced clinical manifestations of PLP deficiency because of prompt replacement therapy. CONCLUSIONS Serial monitoring of serum PLP concentrations is recommended for PN-dependent patients with short-bowel syndrome before and after transplantation for early detection and prompt initiation of preemptive therapy. Long-term measurement at frequent intervals is also recommended, particularly for transplant recipients, to diagnose late deficiency despite achievement of CNA and to prevent toxicity from overdose.
Collapse
Affiliation(s)
- Laura E Matarese
- Thomas E Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Tolerance Induction in a Large-Animal Model Using Total Lymphoid Irradiation and Intrathymic Bone Marrow. Transplantation 2008; 86:1830-6. [DOI: 10.1097/tp.0b013e3181910e67] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
50
|
Abu-Elmagd KM, Costa G, Bond GJ, Wu T, Murase N, Zeevi A, Simmons R, Soltys K, Sindhi R, Stein W, Demetris A, Mazariegos G. Evolution of the immunosuppressive strategies for the intestinal and multivisceral recipients with special reference to allograft immunity and achievement of partial tolerance. Transpl Int 2008; 22:96-109. [PMID: 18954362 DOI: 10.1111/j.1432-2277.2008.00785.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction of new innovative immunosuppressive strategies has been the milestone of the recent evolution of intestinal and multivisceral transplantation. With new insights into the mechanisms of organ engraftment and acquired tolerance, the Pittsburgh tolerogenic protocol was recently introduced and consisted of two main therapeutic principles: recipient pretreatment with lymphoid ablating antibodies and minimal post-transplant immunosuppression with tacrolimus monotherapy. The reported herein improved survival and the striking ability to wean immunosuppression among the intestinal and multivisceral recipients pretreated with a single-dose of Thymoglobulin (rATG) or Campath-1H (alemtuzumab) supports our working hypothesis with successful induction of variable tolerance. It is important, however, that careful monitoring of subtle histologic changes in serial endoscopic-guided mucosal biopsies be carried out for early diagnosis of allograft immune activation with prompt restoration of the baseline immunosuppressive therapy. Future scientific discoveries with better understanding of the mechanisms of immune tolerance and clinical introduction of reliable assays will increase the chance and safety of achieving complete tolerance among the intestinal and other solid organ recipients. This review will focus on the historic evolution of the immunosuppressive and other management strategies utilized for the intestinal and multivisceral recipients at the University of Pittsburgh with special reference to allograft immunity and the successful achievement of partial tolerance.
Collapse
Affiliation(s)
- Kareem M Abu-Elmagd
- Intestinal Rehabilitation and Transplantation Center, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, PA, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|