1
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Muylle E, Van De Winkel N, Hennion I, Dubois A, Thorrez L, Deferm NP, Pirenne J, Ceulemans LJ. Abdominal Wall Closure in Intestinal and Multivisceral Transplantation: A State-Of-The-Art Review of Vascularized Abdominal Wall and Nonvascularized Rectus Fascia Transplantation. Gastroenterol Clin North Am 2024; 53:265-279. [PMID: 38719377 DOI: 10.1016/j.gtc.2023.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Failure to close the abdomen after intestinal or multivisceral transplantation (Tx) remains a frequently occurring problem. Two attractive reconstruction methods, especially in large abdominal wall defects, are full-thickness abdominal wall vascularized composite allograft (AW-VCA) and nonvascularized rectus fascia (NVRF) Tx. This review compares surgical technique, immunology, integration, clinical experience, and indications of both techniques. In AW-VCA Tx, vascular anastomosis is required and the graft undergoes hypotrophy post-Tx. Furthermore, it has immunologic benefits and good clinical outcome. NVRF Tx is an easy technique without the need for vascular anastomosis. Moreover, a rapid integration and neovascularization occurs with excellent clinical outcome.
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Affiliation(s)
- Ewout Muylle
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Herestraat 49, bus 7003, 3000 Leuven, Belgium; Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Chronic Diseases and Metabolism, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Nele Van De Winkel
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Herestraat 49, bus 7003, 3000 Leuven, Belgium; Department of Abdominal Surgery, University Hospitals Leuven, UZ Herestraat 49, bus 7003, 3000 Leuven, Belgium; Department of Development and Regeneration, Unit of Urogenital, Abdominal and Plastic Surgery, KU Leuven, Leuven, Belgium
| | - Ina Hennion
- Tissue Engineering Lab, Department of Development and Regeneration, KU Leuven, KULAK Campus Kortrijk, Etienne Sabbelaan 53, bus 7711, 8500 Kortrijk, Belgium
| | - Antoine Dubois
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Herestraat 49, bus 7003, 3000 Leuven, Belgium; Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology and Transplantation, KU Leuven, UZ Herestraat 49, bus 708, 3000 Leuven, Belgium
| | - Lieven Thorrez
- Tissue Engineering Lab, Department of Development and Regeneration, KU Leuven, KULAK Campus Kortrijk, Etienne Sabbelaan 53, bus 7711, 8500 Kortrijk, Belgium
| | - Nathalie P Deferm
- Department of General and Abdominal Surgery, Sint-Franciscushospital, Pastoor Paquaylaan 129, 3550 Heusden-Zolder, Belgium
| | - Jacques Pirenne
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Herestraat 49, bus 7003, 3000 Leuven, Belgium; Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology and Transplantation, KU Leuven, UZ Herestraat 49, bus 708, 3000 Leuven, Belgium
| | - Laurens J Ceulemans
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Herestraat 49, bus 7003, 3000 Leuven, Belgium; Department of Chronic Diseases and Metabolism, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium; Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.
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2
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Karmi N, Uniken Venema WTC, van der Heide F, Festen EAM, Dijkstra G. Biologicals in the prevention and treatment of intestinal graft rejection: The state of the art: Biologicals in Intestinal Transplantation. Hum Immunol 2024; 85:110810. [PMID: 38788483 DOI: 10.1016/j.humimm.2024.110810] [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: 12/22/2023] [Revised: 04/10/2024] [Accepted: 05/01/2024] [Indexed: 05/26/2024]
Abstract
Intestinal transplantation is the standard treatment for patients with intestinal failure with severe complications due to parenteral nutrition; however, rejection leads to graft failure in approximately half of both adult and pediatric recipients within 5 years of transplantation. Although intensive immunosuppressive therapy is used in an attempt to reduce this risk, commonly used treatment strategies are generally practice- and/or expert-based, as head-to-head comparisons are lacking. In this ever-developing field, biologicals designed to prevent or treat rejection are used increasingly, with both infliximab and vedolizumab showing potential in the treatment of acute cellular rejection in individual cases and in relatively small patient cohorts. To help advance progress in clinical care, we review the current use of biologicals in intestinal transplantation, and we provide future perspectives to guide this progress.
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Affiliation(s)
- Naomi Karmi
- University of Groningen, University Medical Center Groningen, Department of Gastroenterology and Hepatology, Groningen, The Netherlands
| | - Werna T C Uniken Venema
- University of Groningen, University Medical Center Groningen, Department of Gastroenterology and Hepatology, Groningen, The Netherlands
| | - Frans van der Heide
- University of Groningen, University Medical Center Groningen, Department of Gastroenterology and Hepatology, Groningen, The Netherlands
| | - Eleonora A M Festen
- University of Groningen, University Medical Center Groningen, Department of Gastroenterology and Hepatology, Groningen, The Netherlands
| | - Gerard Dijkstra
- University of Groningen, University Medical Center Groningen, Department of Gastroenterology and Hepatology, Groningen, The Netherlands.
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3
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Paulo Guzman J, Maklad M, Osman M, Elsherif A, Fujiki M. Updates in induction immunosuppression regimens for intestinal transplantation. Hum Immunol 2024; 85:110800. [PMID: 38599892 DOI: 10.1016/j.humimm.2024.110800] [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: 01/10/2024] [Revised: 03/08/2024] [Accepted: 04/04/2024] [Indexed: 04/12/2024]
Abstract
Intestinal allografts are the most immunologically complex and carry the highest risk of rejection among solid organ transplantation, necessitating complex immunosuppressive management. We evaluated the latest information regarding induction immunosuppression, with an emphasis on established, novel, and emergent therapies. We also reviewed classic and novel induction immunosuppression strategies for highly sensitized recipients. Comparable progress has been made in intestinal transplantation clinical outcomes since the implementation of induction strategies. This review shows a clear diversity of induction protocols can be observed across different centers. The field of intestinal transplantation is still in its early stages, which is further complicated by the limited number of institutions capable of intestinal transplantation and their geographical variation, which further hinders the development of adequately powered studies in comparison to other organs. As the implementation of institution-specific induction protocols becomes more refined and results are disseminated, future research efforts should be directed towards the development of efficacious induction strategies.
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Affiliation(s)
- Johann Paulo Guzman
- Center for Gut Rehabilitation and Transplantation, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mohamed Maklad
- Center for Gut Rehabilitation and Transplantation, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mohammed Osman
- Center for Gut Rehabilitation and Transplantation, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ayat Elsherif
- Center for Gut Rehabilitation and Transplantation, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Masato Fujiki
- Center for Gut Rehabilitation and Transplantation, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
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4
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Park JS, Cresci GAM. Dysfunctional intestinal microvascular endothelial cells: Insights and therapeutic implications in gastrointestinal inflammation. IMMUNOMETABOLISM (COBHAM, SURREY) 2024; 6:e00043. [PMID: 38818514 PMCID: PMC11136270 DOI: 10.1097/in9.0000000000000043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 05/01/2024] [Indexed: 06/01/2024]
Abstract
The intestinal microvascular endothelium plays a crucial role in orchestrating host responses to inflammation within the gastrointestinal tract. This review delves into the unique aspects of intestinal microvascular endothelial cells, distinct from those of larger vessels, in mediating leukocyte recruitment, maintaining barrier integrity, and regulating angiogenesis during inflammation. Specifically, their role in the pathogenesis of inflammatory bowel diseases, where dysregulated endothelial functions contribute to the disease progression, is reviewed. Furthermore, this review discusses the isolation technique for these cells and commonly used adhesion molecules for in vitro and in vivo experiments. In addition, we reviewed the development and therapeutic implications of a biologic agent targeting the interaction between α4β7 integrin on T lymphocytes and mucosal addressin cellular adhesion molecule-1 on gut endothelium. Notably, vedolizumab, a humanized monoclonal antibody against α4β7 integrin, has shown promising outcomes in inflammatory bowel diseases and other gastrointestinal inflammatory conditions, including chronic pouchitis, immune checkpoint inhibitor-induced colitis, and acute cellular rejection post-intestinal transplantation.
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Affiliation(s)
- Ji Seok Park
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Inflammation & Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gail A. M. Cresci
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Inflammation & Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Children’s Hospital, Cleveland, OH, USA
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Zorzetti N, Marino IR, Sorrenti S, Navarra GG, D'Andrea V, Lauro A. Small bowel transplant - novel indications and recent progress. Expert Rev Gastroenterol Hepatol 2023; 17:677-690. [PMID: 37264646 DOI: 10.1080/17474124.2023.2221433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 05/24/2023] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Advances in the management of intestinal failure have led to a reduction in the number of intestinal transplants. The number of bowel transplants has been mainly stable even though a slight increase has been observed in the last 5 years. AREAS COVERED Standard indication includes patients with a reasonable life expectancy. Recent progress can be deduced by the increased number of intestine transplants in adults: this is due to the continuous improvement of 1-year graft survival worldwide (without differences in 3- and 5-year) associated with better abdominal wall closure techniques. This review aims to provide an update on new indications and changes in trends of pediatric and adult intestine transplantation. This analysis, which stretches through the past 5 years, is based on a collection of related manuscripts from PubMed. EXPERT COMMENTARY Intestinal transplants should be solely intended for a group of individuals for whom indications for transplantation are clear and both medical and surgical rehabilitations have failed. Nevertheless, many protocols developed over the years have not yet solved the key question represented by the over-immunosuppression. Novel indications and recent progress in the bowel transplant field, minimal yet consistent, represent a pathway to be followed.
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Affiliation(s)
- Noemi Zorzetti
- General Surgery, Ospedale Civile "A. Costa", Alto Reno Terme, Bologna, Italy
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Salvatore Sorrenti
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Vito D'Andrea
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Augusto Lauro
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
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Raghu VK, Vetterly CG, Horslen SP. Immunosuppression Regimens for Intestinal Transplantation in Children. Paediatr Drugs 2022; 24:365-376. [PMID: 35604536 DOI: 10.1007/s40272-022-00512-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 10/18/2022]
Abstract
Pediatric intestinal transplant serves as the only definitive treatment for children with irreversible intestinal failure. Successful intestinal transplant hinges upon appropriate management of immunosuppression. The indications for intestinal transplant have changed over time. Immunosuppression regimens can be divided into induction and maintenance phases along with treatment of acute rejection. Intestinal transplant induction now often includes antithymocyte globulin or basiliximab in addition to corticosteroids. Maintenance regimens continue to be dominated by tacrolimus, with additional agents used to either decrease goal tacrolimus levels to limit toxicity or as an adjunct in sensitized patients. Careful monitoring can help to limit serious complications, such as rejection, infection, and malignancy. Future work will aim to decrease variation in practice and identify methods to determine optimal immunosuppression for a particular patient. Furthermore, there is a need for non-invasive monitoring of the intestinal graft and functional assessments of immunosuppression.
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Affiliation(s)
- Vikram Kalathur Raghu
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Pittsburgh, School of Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Carol G Vetterly
- Department of Pharmacy, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Simon Peter Horslen
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Pittsburgh, School of Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
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Fagundes RR, Bourgonje AR, Hu S, Barbieri R, Jansen BH, Sinnema N, Blokzijl T, Taylor CT, Weersma RK, Faber KN, Dijkstra G. HIF1α-Dependent Induction of TFRC by a Combination of Intestinal Inflammation and Systemic Iron Deficiency in Inflammatory Bowel Disease. Front Physiol 2022; 13:889091. [PMID: 35755436 PMCID: PMC9214203 DOI: 10.3389/fphys.2022.889091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/20/2022] [Indexed: 01/04/2023] Open
Abstract
Background and Aims: Iron deficiency (ID) is a frequent extra-intestinal manifestation in patients with Inflammatory Bowel Disease (IBD), who often do not respond to iron supplementation. Iron is a cofactor for hydroxylases that suppress the hypoxia-inducible factor-1α (HIF1α), a transcription factor regulating iron homeostasis. We hypothesized that iron deficiency affects mucosal HIF1α activity in IBD. Methods: IBD patients (n = 101) were subdivided based on iron status (ferritin levels or transferrin saturation) and systemic inflammation (C-reactive protein levels). 154 corresponding ileal and colonic biopsies were analyzed for differential expression of 20 HIF1α pathway-associated genes and related to iron and inflammation status. In vitro expression of selected HIF1α pathway genes were analyzed in wild-type and HIF1A-null Caco-2 cells. Results: Gene expression of the mucosal HIF1α pathway was most affected by intestinal location and inflammatory status. Especially, ileal mucosal TFRC expression, encoding the transferrin receptor TFR1, was increased in inflamed tissue (p < 0.001), and further enhanced in ID. Accordingly, TFRC expression in inflamed tissue associated negatively with serum iron levels, which was not observed in the non-inflamed mucosa. The HIF1α pathway agonist DMOG increased TFRC expression in Caco-2 cells, which was blunted in HIF1A-null cells. Conclusion: We demonstrate that inflammation and anatomical location primarily determine HIF1α pathway activation and downstream TFRC expression in the intestinal mucosa. IBD patients with ID may benefit from treatment with HIF1α-agonists by 1) increasing TFRC-mediated iron absorption in non-inflamed tissue and 2) decreasing mucosal inflammation, thereby improving their responsiveness to oral iron supplementation.
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Affiliation(s)
- Raphael R Fagundes
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Arno R Bourgonje
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Shixian Hu
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Ruggero Barbieri
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Bernadien H Jansen
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Nienke Sinnema
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Tjasso Blokzijl
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Cormac T Taylor
- School of Medicine and Medical Science and the Conway Institute, University College Dublin, Dublin, Ireland
| | - Rinse K Weersma
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Klaas Nico Faber
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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Dogra H, Hind J. Innovations in Immunosuppression for Intestinal Transplantation. Front Nutr 2022; 9:869399. [PMID: 35782951 PMCID: PMC9241336 DOI: 10.3389/fnut.2022.869399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 05/03/2022] [Indexed: 11/13/2022] Open
Abstract
It has been 57 years since the first intestinal transplant. An increased incidence of graft rejection has been described compared to other solid organ transplants due to high immunogenicity of the bowel, which in health allows the balance between of dietary antigen with defense against pathogens. Expanding clinical experience, knowledge of gastrointestinal physiology and immunology have progress post-transplant immunosuppressive drug regimens. Current regimes aim to find the window between prevention of rejection and the risk of infection (the leading cause of death) and malignancy. The ultimate aim is to achieve graft tolerance. In this review we discuss advances in mucosal immunology and technologies informing the development of new anti-rejection strategies with the hope of improved survival in the next generation of transplant recipients.
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9
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Szczepanik A, Choi D, Brady B, Chandran MM, Diamond A, Do V, Fredrick S, Kaiser T, Khalil K, Laub MR, Leino A, Park JM, Pierce D, Rendulic T, Wiegel JJ, Fose J, Jorgenson MR. The use of non-transplant biologics in solid organ transplant recipients: A practical review for the frontline clinician. Clin Transplant 2022; 36:e14743. [PMID: 35690919 DOI: 10.1111/ctr.14743] [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: 02/18/2022] [Revised: 05/09/2022] [Accepted: 06/01/2022] [Indexed: 11/27/2022]
Abstract
Biologics have become the forefront of medicine for management of autoimmune conditions, leading to improved quality of life. Many autoimmune conditions occur in solid organ transplant (SOT) recipients and persist following transplant. However, the use of biologics in this patient population is not well studied, and questions arise related to risk of infection and adjustments to induction and maintenance immunosuppression. Guidelines have been published highlighting management strategies of biologics around the time of elective surgical procedures, but this is not always feasible in urgent situations, especially with deceased donor transplantation. The aim of this review is to summarize the current literature regarding the use of these agents in solid organ transplant recipients, and specifically address induction and maintenance immunosuppression, as well as the need for alternative infective prevention strategies to create a practical reference for the frontline clinician, when faced with this complex clinical scenario.
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Affiliation(s)
- Amanda Szczepanik
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - David Choi
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, USA
| | | | | | | | - Vincent Do
- Department of Pharmacy, Yale New Haven Hospital, New Haven, Connecticut, USA
| | | | | | | | - Melissa R Laub
- Department of Pharmacy, Augusta University Medical Center, Augusta, Georgia, USA
| | - Abbie Leino
- Department of Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Jeong M Park
- Department of Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Dana Pierce
- Department of Pharmacy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | | | | | - Jillian Fose
- Department of Pharmacy, UW Health, Madison, Wisconsin, USA
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10
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Merola J, Shamim A, Weiner J. Update on immunosuppressive strategies in intestinal transplantation. Curr Opin Organ Transplant 2022; 27:119-125. [PMID: 35232925 PMCID: PMC8915446 DOI: 10.1097/mot.0000000000000958] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The intestine is the most immunologically complex solid organ allograft with the greatest risk of both rejection and graft-versus-host disease (GVHD). High levels of immunosuppression are required, further increasing morbidity. Due to low volume of transplants and few centers with experience, there is paucity of evidence-based, standardized, and effective therapeutic regimens. We herein review the most recent data about immunosuppression, focusing on novel and emerging therapies. RECENT FINDINGS Recent data are moving the field toward increasing use of basilixumab and consideration of alemtuzumab for induction and inclusion of mammalian target of rapamycin inhibitors and antimetabolites for maintenance. For rejection, we highlight novel roles for tumor necrosis factor-α inhibition, α4β7 integrin inhibition, microbiome modulation, desensitization protocols, and tolerance induction strategies. We also highlight emerging novel therapies for GVHD, especially the promising role of Janus kinase inhibition. SUMMARY New insights into immune pathways associated with rejection and GVHD in intestinal allografts have led to an evolution of therapies from broad-based immunosuppression to more targeted strategies that hold promise for reducing morbidity from infection, rejection, and GVHD. These should be the focus of further study to facilitate their widespread use.
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Affiliation(s)
- Jonathan Merola
- Department of Surgery, Columbia University Irving Medical Center, New York, NY 10032
| | - Abrar Shamim
- Columbia University College of Dental Medicine, New York, NY 10032
- Columbia Center for Translational Immunology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY 10032
| | - Joshua Weiner
- Department of Surgery, Columbia University Irving Medical Center, New York, NY 10032
- Columbia Center for Translational Immunology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY 10032
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11
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Bustos VP, Escandón JM, Santamaría E, Ciudad P, Forte AJ, Hernandez-Alejandro R, Leckenby JI, Langstein HN, Manrique OJ. Abdominal Wall Vascularized Composite Allotransplantation: A Scoping Review. J Reconstr Microsurg 2021; 38:481-490. [PMID: 34905782 DOI: 10.1055/s-0041-1740121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Abdominal wall vascularized composite allotransplantation (AW-VCA) is a novel reconstructive technique used for large abdominal wall defects in combination with intestinal transplantation (ITx) or multivisceral abdominal transplantation (MVTx). Since the introduction of this procedure, several studies have been published reporting their experience. This study aims to present a scoping review looking at all available evidence-based medicine information to understand the most current surgical techniques and clinical outcomes. METHODS This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) extension for scoping reviews checklist. A comprehensive research strategy of several databases was conducted. RESULTS A total of 31 studies were included in this review, which comprised animal, cadaveric, and human studies. In human studies, four surgical techniques with high flap survival rates and low complication rates were found. In cadaveric studies, it was shown that the use of iliofemoral cuff-based flaps provided adequate tissue perfusion to the abdominal wall graft. Also, the use of thoracolumbar nerves have been described to provide functionality to the AW-VCA and prevent long-term muscle atrophy. CONCLUSION AW-VCA is a safe and efficient alternative for patients with large and complex abdominal wall defects. The future holds a promising evolution of a functional AW-VCA, though surgeons must face and overcome the challenge of distorted anatomy frequently present in this population. Forthcoming studies with a better level of evidence are required to evaluate functionality and differences between surgical techniques.
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Affiliation(s)
- Valeria P Bustos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Eric Santamaría
- Department of Plastic and Reconstructive Surgery, Hospital General Dr. Manuel Gea Gonzalez, National Cancer Institute, Mexico City, Mexico
| | - Pedro Ciudad
- Department of Plastic, Reconstructive, and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Antonio J Forte
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Jacksonville, Florida
| | - Roberto Hernandez-Alejandro
- Division of Abdominal Transplantation and Hepatobiliaty Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Jonathan I Leckenby
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Howard N Langstein
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
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12
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Abstract
Abstract
Purpose of Review
This article aims to review published outcomes associated with full-thickness vascularized abdominal wall transplantation, with particular emphasis on advances in the field in the last 3 years.
Recent Findings
Forty-six full-thickness vascularized abdominal wall transplants have been performed in 44 patients worldwide. Approximately 35% of abdominal wall transplant recipients will experience at least one episode of acute rejection in the first year after transplant, compared with rejection rates of 87.8% and 72.7% for hand and face transplant respectively. Recent evidence suggests that combining a skin containing abdominal wall transplant with an intestinal transplant does not appear to increase sensitization or de novo donor-specific antibody formation.
Summary
Published data suggests that abdominal wall transplantation is an effective safe solution to achieve primary closure of the abdomen after intestinal or multivisceral transplant. However, better data is needed to confirm observations made and to determine long-term outcomes, requiring standardized data collection and reporting and collaboration between the small number of active transplant centres around the world.
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