1
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Bryan NS, Russell SC, Ozler O, Sugiguchi F, Yazigi NA, Khan KM, Ekong UD, Vitola BE, Guerra JF, Kroemer A, Fishbein TM, Matsumoto CS, Ghobrial SS, Kaufman SS. Evaluation of pediatric patients for intestinal transplantation in the modern era. J Pediatr Gastroenterol Nutr 2024; 79:278-289. [PMID: 38828781 DOI: 10.1002/jpn3.12274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 04/26/2024] [Accepted: 05/14/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVES To review recent evaluations of pediatric patients with intestinal failure (IF) for intestinal transplantation (ITx), waiting list decisions, and outcomes of patients listed and not listed for ITx at our center. METHODS Retrospective chart review of 97 patients evaluated for ITx from January 2014 to December 2021 including data from referring institutions and protocol laboratory testing, body imaging, endoscopy, and liver biopsy in selected cases. Survival analysis used Kaplan-Meier estimates and Cox proportional hazards regression. RESULTS Patients were referred almost entirely from outside institutions, one-third because of intestinal failure-associated liver disease (IFALD), two-thirds because of repeated infective and non-IFALD complications under minimally successful intestinal rehabilitation, and a single patient because of lost central vein access. The majority had short bowel syndrome (SBS). Waiting list placement was offered to 67 (69%) patients, 40 of whom for IFALD. The IFALD group was generally younger and more likely to have SBS, have received more parenteral nutrition, have demonstrated more evidence of chronic inflammation and have inferior kidney function compared to those offered ITx for non-IFALD complications and those not listed. ITx was performed in 53 patients. Superior postevaluation survival was independently associated with higher serum creatinine (hazard ratio [HR] 15.410, p = 014), whereas inferior postevaluation survival was associated with ITx (HR 0.515, p = 0.035) and higher serum fibrinogen (HR 0.994, p = 0.005). CONCLUSIONS Despite recent improvements in IF management, IFALD remains a prominent reason for ITx referral. Complications of IF inherent to ITx candidacy influence postevaluation and post-ITx survival.
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Affiliation(s)
- Nathan S Bryan
- Department of Pediatrics, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Shannon C Russell
- Department of Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Oguz Ozler
- Department of Pediatrics, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Fumitaka Sugiguchi
- Department of Pediatrics, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Nada A Yazigi
- Medstar Georgetown Transplant Institute, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Khalid M Khan
- Medstar Georgetown Transplant Institute, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Udeme D Ekong
- Medstar Georgetown Transplant Institute, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Bernadette E Vitola
- Medstar Georgetown Transplant Institute, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Juan-Francisco Guerra
- Medstar Georgetown Transplant Institute, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Alexander Kroemer
- Medstar Georgetown Transplant Institute, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Thomas M Fishbein
- Medstar Georgetown Transplant Institute, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Cal S Matsumoto
- Medstar Georgetown Transplant Institute, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Shahira S Ghobrial
- Department of Pharmacy, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Stuart S Kaufman
- Medstar Georgetown Transplant Institute, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
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2
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Sykes M. Tolerance in intestinal transplantation. Hum Immunol 2024; 85:110793. [PMID: 38580539 PMCID: PMC11144570 DOI: 10.1016/j.humimm.2024.110793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/07/2024]
Abstract
Intestinal transplantation (ITx) is highly immunogenic, resulting in the need for high levels of immunosuppression, with frequent complications along with high rejection rates. Tolerance induction would provide a solution to these limitations. Detailed studies of alloreactive T cell clones as well as multiparameter flow cytometry in the graft and peripheral tissues have provided evidence for several tolerance mechanisms that occur spontaneously following ITx, which might provide targets for further interventions. These include the frequent occurrence of macrochimerism and engraftment in the recipient bone marrow of donor hematopoietic stem and progenitor cells carried in the allograft. These phenomena are seen most frequently in recipients of multivisceral transplants and are associated with reduced rejection rates. They reflect powerful graft-vs-host responses that enter the peripheral lymphoid system and bone marrow after expanding within and emigrating from the allograft. Several mechanisms of tolerance that may result from this lymphohematopoietic graft-vs-host response are discussed. Transcriptional profiling in quiescent allografts reveals tolerization of pre-existing host-vs-graft-reactive T cells that enter the allograft mucosa and become tissue-resident memory cells. Dissection of the pathways driving and maintaining this tolerant tissue-resident state among donor-reactive T cells will allow controlled tolerance induction through specific therapeutic approaches.
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Affiliation(s)
- Megan Sykes
- Columbia Center for Translational Immunology, Department of Medicine, Department of Microbiology and Immunology and Department of Surgery, Columbia University, New York, NY, USA.
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3
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Oza K, Kang J, Patil D, Owen KL, Cui W, Khan K, Kaufman SS, Kroemer A. Current Advances in Graft-versus-host Disease After Intestinal Transplantation. Transplantation 2024; 108:399-408. [PMID: 37309025 DOI: 10.1097/tp.0000000000004703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Graft-versus-host disease (GvHD) remains a potentially fatal complication following intestinal transplant (ITx). Over the past decade, advances in the understanding of the pathophysiology of this complex immunological phenomenon have led to the reassessment of the host systemic immune response and have created a gateway for novel preventive and therapeutic strategies. Although sufficient evidence dictates the use of corticosteroids as a first-line option, the treatment for refractory disease remains contentious and lacks a standardized therapeutic approach. Timely diagnosis remains crucial, and the advent of chimerism detection and immunological biomarkers have transformed the identification, prognostication, and potential for survival after GvHD in ITx. The objectives of the following review aim to discuss the clinical and diagnostic features, pathophysiology, advances in immune biomarkers, as well as therapeutic opportunities in the prevention and treatment of GvHD in ITx.
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Affiliation(s)
- Kesha Oza
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
- Department of General Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Jiman Kang
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
- Department of Biochemistry and Molecular & Cellular Biology, Georgetown University, Washington, DC
| | - Digvijay Patil
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Kathryn L Owen
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Wanxing Cui
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
- Department of Biochemistry and Molecular & Cellular Biology, Georgetown University, Washington, DC
| | - Khalid Khan
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Stuart S Kaufman
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Alexander Kroemer
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
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4
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Hussan E, Kroemer A, Elsabbagh AM, Khan KM, Yazigi NA, Ekong UD, Subramanian S, Ghobrial SS, Guerra JF, Fishbein TM, Matsumoto CS, Kaufman SS. Idiopathic Ileal Ulceration After Intestinal Transplantation. Transplant Direct 2023; 9:e1529. [PMID: 37899780 PMCID: PMC10602531 DOI: 10.1097/txd.0000000000001529] [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: 05/11/2023] [Revised: 06/09/2023] [Accepted: 06/19/2023] [Indexed: 10/31/2023] Open
Abstract
Background Idiopathic ileal ulceration after intestinal transplantation (ITx) has been discussed infrequently and has an uncertain natural history and relation to graft rejection. Herein, we review our experience with this pathology. Methods We retrospectively reviewed 225 ITx in 217 patients with minimum 1 y graft survival. Routine graft endoscopy was conducted up to twice weekly within the first 90 d after ITx, gradually decreasing to once yearly. Risks for ulceration over time were evaluated using Cox regression. Results Of 93 (41%) patients with ulcers, 50 were found within 90 d after ITx mostly via ileoscopy; delayed healing after biopsy appeared causal in the majority. Of the remaining 43 patients with ulcers found >90 d after ITx, 36 were after ileostomy closure. Multivariable modeling demonstrated within 90-d ulcer associations with increasing patient age (hazard ratio [HR], 1.027; P < 0.001) and loop ileostomy (versus Santulli ileostomy; HR, 0.271; P < 0.001). For ulcers appearing after ileostomy closure, their sole association was with absence of graft colon (HR, 7.232; P < 0.001). For ulcers requiring extended anti-microbial and anti-inflammatory therapy, associations included de novo donor-specific antibodies (HR, 3.222; P < 0.007) and nucleotide oligomerization domain mutations (HR, 2.772; P < 0.016). Whole-cohort post-ITx ulceration was not associated with either graft rejection (P = 0.161) or graft failure (P = 0.410). Conclusions Idiopathic ulceration after ITx is relatively common but has little independent influence on outcome; risks include ileostomy construction, colon-free ITx, immunologic mutation, and donor sensitization.
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Affiliation(s)
- Elsadig Hussan
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
| | - Alexander Kroemer
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Ahmed M. Elsabbagh
- Gastroenterology Surgical Center, Department of Surgery, Mansoura University, Mansoura, Egypt
| | - Khalid M. Khan
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Nada A. Yazigi
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Udeme D. Ekong
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Sukanya Subramanian
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | | | - Juan-Francisco Guerra
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Thomas M. Fishbein
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Cal S. Matsumoto
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Stuart S. Kaufman
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
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5
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Dasyam AK, Borhani AA, Tirukkovalur NV, Cruz RJ. Intestinal and Multivisceral Transplantation: Complications. Radiol Clin North Am 2023; 61:871-887. [PMID: 37495294 DOI: 10.1016/j.rcl.2023.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Advancements in immunosuppression protocols, surgical techniques, and postoperative care in the last few decades have improved outcomes of intestinal transplant patients. Normal immediate postoperative imaging appearance can simulate pathology. Intestinal transplant recipients are prone for several postoperative complications due to the complex surgical technique, which involves multiple anastomoses, and immunogenic nature of the allograft intestine. Imaging plays a crucial role in detection of several major complications including infectious, immunologic, vascular, gastrointestinal, pancreaticobiliary, genitourinary, and neoplastic complications. The awareness of the posttransplant anatomy and normal imaging appearances helps radiologists anticipate and accurately detect posttransplant complications.
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Affiliation(s)
- Anil K Dasyam
- Department of Radiology, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA 15216, USA.
| | - Amir A Borhani
- Department of Radiology, Northwestern University Feinberg School of Medicine, 676 North Street Claire Street, Suite 800, Chicago, IL 60611, USA
| | - Nikhil V Tirukkovalur
- Kamineni Academy of Medical Science and Research Centre, LB Nagar, Hyderabad, TG 500068, India
| | - Ruy J Cruz
- Intestinal Rehabilitation and Multivisceral Transplant Program, Starzl Transplant Institute
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6
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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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7
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Yue C, Wu X, Mo Z, Yang Q, Wang W, Zhou H, Gao R, Liang J, Yu P, Zhang Y, Ji G, Li X. Multidrug-resistant Klebsiella Pneumoniae Infection Led to Resection of the Graft in a Small Bowel Transplant Recipient: A Case Report and Review of the Literature. Transplant Proc 2023:S0041-1345(23)00254-3. [PMID: 37225551 DOI: 10.1016/j.transproceed.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/27/2023] [Accepted: 04/11/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Infection due to multidrug-resistant Klebsiella pneumoniae is a common cause of graft resection after small bowel transplantation. We report a failed case in which the intestinal graft was resected 18 days after the operation due to postoperative infection with multidrug-resistant K pneumoniae and a literature review of other common causes of small bowel transplantation failure have been reported. METHODS A female, 29 years of age, underwent partial living small bowel transplantation for short bowel syndrome. After the operation, the patient was infected with multidrug-resistant K pneumoniae, even though various anti-infective regimens were employed. It further developed into sepsis and disseminated into intravascular coagulation, leading to exfoliation and necrosis of the intestinal mucosa. Finally, the intestinal graft had to be resected to save the patient's life. RESULTS Multidrug-resistant K pneumoniae infection often affects the biological function of intestinal grafts and can even lead to necrosis. Other common causes of failure, including postoperative infection, rejection, post-transplantation lymphoproliferative disorder, graft-vs-host disease, surgical complications, and other related diseases, were also discussed throughout the literature review. CONCLUSIONS Pathogenesis due to diverse and interrelated factors makes the survival of intestinal allografts a great challenge. Therefore, only by fully understanding and mastering the common causes of surgical failure can the success rate of small bowel transplantation be effectively improved.
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Affiliation(s)
- Chao Yue
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Xiao Wu
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Zhenchang Mo
- Department of Oncology, Affiliated Hospital, Shaanxi University of Chinese Medicine, Shaanxi, China
| | - Qinchuan Yang
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Weidong Wang
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Haikun Zhou
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Ruiqi Gao
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Jiayi Liang
- Department of Pathology, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Pengfei Yu
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Ying Zhang
- Department of Radiotherapy, Xijing Hospital, Air Force Medical University, Shaanxi, China.
| | - Gang Ji
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China.
| | - Xiaohua Li
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China.
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8
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Abstract
PURPOSE OF REVIEW The role of intestinal transplant has expanded in recent years and is no longer only considered for patients with no other options remaining. 5 year survival in high-volume centres is over 80% for certain graft types. The aim of this review is to update the audience on the current state of intestinal transplant, with a focus on recent medical and surgical advances. RECENT FINDINGS There has been a greater understanding of the interplay and balance of host and graft immune responses, which may facilitate individualized immunosuppression. Some centres are now performing 'no-stoma' transplants, with preliminary data showing no adverse effects from this strategy and other surgical advances have lessened the physiological insult of the transplant operation. Earlier referrals are encouraged by transplant centres, such that vascular access or liver disease has not progressed too much to increase the technical and physiological challenge of the procedure. SUMMARY Clinicians should consider intestinal transplant as a viable option for patients with intestinal failure, benign unresectable abdominal tumours or acute abdominal catastrophes.
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Affiliation(s)
| | - Neil K Russell
- Department of Transplant Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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9
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Girlanda R, Liggett JR, Jayatilake M, Kroemer A, Guerra JF, Hawksworth JS, Radkani P, Matsumoto CS, Zasloff M, Fishbein TM. The Microbiome and Metabolomic Profile of the Transplanted Intestine with Long-Term Function. Biomedicines 2022; 10:biomedicines10092079. [PMID: 36140180 PMCID: PMC9495872 DOI: 10.3390/biomedicines10092079] [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: 07/18/2022] [Revised: 08/14/2022] [Accepted: 08/16/2022] [Indexed: 11/25/2022] Open
Abstract
We analyzed the fecal microbiome by deep sequencing of the 16S ribosomal genes and the metabolomic profiles of 43 intestinal transplant recipients to identify biomarkers of graft function. Stool samples were collected from 23 patients with stable graft function five years or longer after transplant, 15 stable recipients one-year post-transplant and four recipients with refractory rejection and graft loss within one-year post-transplant. Lactobacillus and Streptococcus species were predominant in patients with stable graft function both in the short and long term, with a microbiome profile consistent with the general population. Conversely, Enterococcus species were predominant in patients with refractory rejection as compared to the general population, indicating profound dysbiosis in the context of graft dysfunction. Metabolomic analysis demonstrated significant differences between the three groups, with several metabolites in rejecting recipients clustering as a distinct set. Our study suggests that the bacterial microbiome profile of stable intestinal transplants is similar to the general population, supporting further application of this non-invasive approach to identify biomarkers of intestinal graft function.
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Affiliation(s)
- Raffaelle Girlanda
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Center for Translational Transplant Medicine, Georgetown University, Washington, DC 20007, USA
- Correspondence:
| | - Jedson R. Liggett
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Center for Translational Transplant Medicine, Georgetown University, Washington, DC 20007, USA
- Department of Surgery, Naval Medical Center Portsmouth, Portsmouth, VA 23704, USA
| | - Meth Jayatilake
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC 20007, USA
| | - Alexander Kroemer
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Center for Translational Transplant Medicine, Georgetown University, Washington, DC 20007, USA
| | - Juan Francisco Guerra
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Center for Translational Transplant Medicine, Georgetown University, Washington, DC 20007, USA
| | - Jason Solomon Hawksworth
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Center for Translational Transplant Medicine, Georgetown University, Washington, DC 20007, USA
- Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20812, USA
| | - Pejman Radkani
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Center for Translational Transplant Medicine, Georgetown University, Washington, DC 20007, USA
| | - Cal S. Matsumoto
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Center for Translational Transplant Medicine, Georgetown University, Washington, DC 20007, USA
| | - Michael Zasloff
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Center for Translational Transplant Medicine, Georgetown University, Washington, DC 20007, USA
| | - Thomas M. Fishbein
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Center for Translational Transplant Medicine, Georgetown University, Washington, DC 20007, 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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A study of the mechanisms responsible for the action of new immunosuppressants and their effects on rat small intestinal transplantation. Transpl Immunol 2021; 70:101497. [PMID: 34785307 DOI: 10.1016/j.trim.2021.101497] [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: 08/19/2021] [Revised: 11/08/2021] [Accepted: 11/08/2021] [Indexed: 11/20/2022]
Abstract
In a series of studies, using an identical rat intestinal transplantation model, we evaluated the effects of several drugs. FK-506 caused a significant attenuation in the proliferation of allogeneic CD4+ T cells and IFN-γ secreting effector functions. FYT720 resulted in a marked reduction in the numbers of lymphocytes, associated with a reduction of T cell recruitment, in grafts. An anti-MAdCAM antibody was next reported to significantly down-regulate CD4+ T cell infiltration in intestinal grafts by blocking the adhesion molecule, and could be useful as an induction therapy. Concerning TAK-779, this CCR5 and CXCR3 antagonist diminished the number of graft-infiltrating cells by suppressing the expression of their receptors in the graft. As a result, it reduced the total number of recipient T cells involved in graft rejection. As the next step, we focused on the participation of monocytes/ macrophages in this field. PQA-18 has been the focus of a novel immunosuppressant that attenuates not only the production of various cytokines, such as IL-2 & TNF-α, on T cells, but the differentiation of macrophages by inhibiting PAK2 as well. In this report, we summarize our previous studies not only regarding the above drugs, but on an anti-complement drug and a JAK inhibitor as well.
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