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Garcia J, Vianna R. B-Cell Induction Therapies in Intestinal Transplantation. Gastroenterol Clin North Am 2024; 53:343-357. [PMID: 39067999 DOI: 10.1016/j.gtc.2024.01.001] [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] [Indexed: 07/30/2024]
Abstract
Despite advancements in short-term outcomes since the inception of intestinal transplant, significant long-term graft failure persists. Early successes are attributed to the utilization of tacrolimus for maintenance therapy, coupled with T-cell modulating induction regimens, which effectively reduce the incidence of acute cellular rejection. However, the challenge of chronic allograft injury remains unresolved. There is increasing evidence indicating a correlation between donor-specific antibodies and the survival of visceral allografts. Strategies aimed at reducing the presence or load of these antibodies may potentially enhance long-term outcomes. Consequently, our focus is now turning toward B-cell induction therapies as a possible solution.
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Affiliation(s)
- Jennifer Garcia
- Adult and Pediatric Intestinal Transplant, Miami Transplant Institute, University of Miami-Jackson Memorial Hospital, 1801 Northwest 9th Avenue, MTI 7th Floor, Jackson Professional Building, Miami, FL 33136, USA.
| | - Rodrigo Vianna
- Adult and Pediatric Intestinal Transplant, Miami Transplant Institute, University of Miami-Jackson Memorial Hospital, 1801 Northwest 9th Avenue, MTI 7th Floor, Jackson Professional Building, Miami, FL 33136, USA
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2
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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.
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Affiliation(s)
- Gabriel E Gondolesi
- Chief of General Surgery, Chief of Liver, Intestine and Pancreas Transplant, Hospital Universitario, Fundación Favaloro, Buenos Aires, Argentina.
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3
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Xu Q, Zeevi A, Ganoza A, Cruz RJ, Mazariegos GV. Current approaches for risk assessment of intestinal transplant patients: A view from the histocompatibility laboratory. Hum Immunol 2024; 85:110768. [PMID: 38433035 DOI: 10.1016/j.humimm.2024.110768] [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: 01/25/2024] [Revised: 02/12/2024] [Accepted: 02/21/2024] [Indexed: 03/05/2024]
Abstract
Despite its recent decline in volumes, intestinal transplantation remains an important option for patients with irreversible intestinal failures. The long-term outcome of an intestinal transplant has stagnated. The major cause of graft loss is rejection, resulting from mismatches in human leukocyte antigens (HLA) and the presence of antibodies to mismatched donor-specific HLA antigens (DSA). Literature has reported that DSAs, either preformed before transplantation or developed de novo after transplantation, are harmful to intestinal grafts, especially for those without combined liver grafts. A comprehensive assessment of DSA by the histocompatibility laboratory is critical for successful intestinal transplantation and its long-term survival. This paper briefly reviews the history and current status of different methods for detecting DSA and their clinical applications in intestinal transplantation. The focus is on applying different antibody assays to manage immunologically challenging intestinal transplant patients before and after transplantation. A clinical case is presented to illustrate the complexity of HLA tests and the necessity of multiple assays. The review of risk assessment by the histocompatibility laboratory also highlights the need for close interaction between the laboratory and the intestinal transplant program.
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Affiliation(s)
- Qingyong Xu
- Department of Pathology, University of Pittsburgh, USA.
| | - Adriana Zeevi
- Department of Pathology, University of Pittsburgh, USA
| | | | - Ruy J Cruz
- Department of Surgery, University of Pittsburgh, USA; Gastrointestinal Rehabilitation and Transplant Center, Starzl Transplantation Institute, USA
| | - George V Mazariegos
- Department of Surgery, University of Pittsburgh, USA; Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, USA
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4
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Wu G, Liu C, Ma N, Zhou X, Zhao L, Zhang Y, Zhang W, Liang T. Successful combined auxiliary partial liver and intestinal transplantation in two highly sensitized, cross-match positive patients. Clin Transplant 2023; 37:e14865. [PMID: 36416299 DOI: 10.1111/ctr.14865] [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: 07/14/2022] [Revised: 09/09/2022] [Accepted: 10/29/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Sensitization to human leukocyte antigen (HLA) creates an immunological barrier to intestinal transplantation (ITx). Current desensitization therapies are limited and ineffective in the most highly sensitized patients. A co-transplanted whole liver transplant can protect a kidney, heart, or intestinal allograft from antibody-mediated injury. Whether an auxiliary partial liver allograft provides effective protection for highly sensitized intestinal transplant recipients is unknown. METHODS Two patients with strong HLA donor-specific antibody at high titer against their deceased donors underwent combined auxiliary partial liver and ITx across a positive cross-match. The left lateral lobes from the combined-graft recipients and the right liver lobes from the deceased donors were transplanted as a domino procedure to other four patients. RESULTS Two combined-graft recipients have had an uneventful postoperative course without major complications at a 12- and 24-month follow-up, respectively. Intestinal graft function has been excellent with no evidence of humoral or cellular rejection. While a positive cross-match turned negative, titers of donor-specific HLA antibodies gradually declined over time after transplant. The left liver lobes procured from the combined-graft recipients were successfully transplanted into two pediatric patients (age 1.9, 2.4 years) and the right lobes from two deceased donors were successfully transplanted into two adult patients. All transplant procedures went well, without post-operative complications related to the splitting technique. CONCLUSION Our results indicate that an auxiliary liver transplant can effectively protect a co-transplanted intestinal allograft against rejection and suggest that this combined procedure may serve as a useful therapeutic adjunct for a highly sensitized intestinal transplant candidate.
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Affiliation(s)
- Guosheng Wu
- Intestinal Transplant Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chaoxu Liu
- Intestinal Transplant Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Nan Ma
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xile Zhou
- Intestinal Transplant Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Long Zhao
- Intestinal Transplant Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuntao Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wentong Zhang
- Intestinal Transplant Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang University Cancer Center, Zhejiang University, Hangzhou, China
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5
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Wade J, Roback JD, Krummey SM, Gebel HM, Bray RA, Sullivan HC. Implementing virtual crossmatch based diagnostic management teams in human leukocyte antigen laboratories and transplant programs. Transpl Immunol 2022; 73:101629. [DOI: 10.1016/j.trim.2022.101629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/10/2022] [Accepted: 05/17/2022] [Indexed: 11/25/2022]
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Moon JI, Ko HM, Iyer KR. Enhanced virtual crossmatch in intestinal transplantation: association with outcomes and application in practice. KOREAN JOURNAL OF TRANSPLANTATION 2021; 35:230-237. [PMID: 35769851 PMCID: PMC9235456 DOI: 10.4285/kjt.21.0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/19/2021] [Accepted: 12/06/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Jang Il Moon
- Recanati Miller Transplantation Institute and Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Huaibin M Ko
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kishore R Iyer
- Recanati Miller Transplantation Institute and Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Graft Versus Host Disease After Intestinal Transplantation: A Single-center Experience. Transplant Direct 2021; 7:e731. [PMID: 34291153 PMCID: PMC8291352 DOI: 10.1097/txd.0000000000001187] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 04/13/2021] [Indexed: 12/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. Background. Graft versus host disease (GVHD) is an uncommon but highly morbid complication of intestinal transplantation (ITx). In this study, we reviewed our 17-y experience with GVHD focusing on factors predicting GVHD occurrence and survival. Methods. Retrospective review of 271 patients who received 1 or more ITx since program inception in 2003 with survival analysis using Cox proportional hazard modeling. Results. Of 271 patients, 28 developed GHVD 34 (18–66) d after ITx presenting with rash or rash with fever in 26, rectosigmoid disease in 1, and hemolysis in 1; other sites, mainly rectosigmoid colon, were involved in 13. Initial skin biopsy demonstrated classic findings in 6, compatible findings in 14, and no abnormalities in 2. Additional sites of GVHD later emerged in 14. Of the 28 patients, 16 died largely from sepsis, the only independent hazard for death (hazard ratio [HR], 37.4181; P = 0.0008). Significant (P < 0.0500) independent hazards for occurrence of GVHD in adults were pre-ITx functional intestinal failure (IF) (HR, 15.2448) and non-IF diagnosis (HR, 20.9952) and early post-ITx sirolimus therapy (HR, 0.0956); independent hazards in children were non-IF diagnosis (HR, 4.3990), retransplantation (HR, 4.6401), donor:recipient age ratio (HR, 7.3190), and graft colon omission (HR, 0.1886). Variant transplant operation was not an independent GVHD hazard. Conclusions. Initial diagnosis of GVHD after ITx remains largely clinical, supported but not often confirmed by skin biopsy. Although GVHD risk is mainly recipient-driven, changes in donor selection and immunosuppression practice may reduce incidence and improve survival.
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Donor-specific antibody and sensitized patients in intestinal transplantation. Curr Opin Organ Transplant 2021; 26:245-249. [PMID: 33528224 DOI: 10.1097/mot.0000000000000853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW It has been well established that antibody to donor HLA pretransplant and the development of anti-human leukocyte antigen (HLA) antibodies posttransplant contribute to inferior graft survival outcomes. This article serves to review the current status of the management of pretransplant sensitized intestinal transplant candidate as well as to review posttransplant care of patients that harbor antidonor HLA antibodies. RECENT FINDINGS The intestinal transplant candidate oftentimes presents for transplant listing with high levels of anti-HLA antibodies that necessitate a careful preoperative strategy to avoid a donor-recipient pair that would result in a positive crossmatch. In the end, donor intestine offer acceptance is based on a balance between recipient clinical needs and allowable immunologic risk tolerance. The use of virtual crossmatching (VXM) enables the transplant center to effectively gauge the immunologic risk of each potential donor-recipient pair far in advance of allocating resources toward pursuing a donor organ. In those candidates with high levels of preformed donor anti-HLA antibodies, desensitization with a novel technique of donor splenic perfusion has been described as well as a single-center experience with a conventional desensitizing protocol. Posttransplant, with the use of a denovo donor-specific antibody (dnDSA) monitoring and treatment protocol, the well known deleterious effects of dnDSA can potentially be ameliorated, thus improving outcome. Efforts to establish a formal histologic criteria for antibody-mediated rejection (ABMR) in the intestinal graft continues to evolve with recent findings describing the relationship between DSA and histopathologic findings. SUMMARY Techniques such as the use of VXM, novel desensitization methods and protocols, monitoring and eradicating dnDSA, along with establishing new criteria for ABMR have all contributed to improving the outcomes in transplanting the immunologically challenging intestine.
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Factors Associated With 5- and 10-Year Survival After Intestinal Transplantation in Infants and Children. J Pediatr Gastroenterol Nutr 2020; 71:617-623. [PMID: 33093368 DOI: 10.1097/mpg.0000000000002849] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Intestinal transplantation is an option for permanent intestinal failure with parenteral nutrition intolerance. We sought to determine long-term intestinal graft survival in pediatric patients at our center and to identify factors influencing survival. METHODS Retrospective chart review of 86 patients transplanted between 2003 and 2013, targeting potential explanatory variables related to demographics, perioperative factors, and postoperative complications. RESULTS Intestinal graft survival was 71% and 65% after 5 and 10 years, respectively. Five-year graft survival was attained in 79% of patients with a history of anatomic intestinal failure compared with 45% with functional intestinal failure (P = 0.0055). Compared with nonsurvival, 5-year graft survival was also associated with reduced incidences of graft-versus-host disease (2% vs 16%, P = 0.0237), post-transplant lymphoproliferative disorder (3% vs 24%, P = 0.0067), and de novo donor-specific antibodies (19% vs 57%, P = 0.0451) plus a lower donor-recipient weight ratio (median 0.727 vs 0.923, P = 0.0316). Factors not associated with 5-year intestinal graft survival included graft rejection of any severity and inclusion of a liver graft. Factors associated with graft survival at 10 years were similar to those at 5 years. CONCLUSIONS In our experience, outcomes in pediatric intestinal transplantation have improved substantially for anatomic but not functional intestinal failure. Graft survival depends on avoidance of severe infectious and immunological complications including GVHD, whereas inclusion of a liver graft provides no obvious survival benefit. Reduced success with functional intestinal failure may reflect inherently increased susceptibility to complications in this group.
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10
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Immunologic Complications and Graft Survival in Crohn's Disease and NOD2 Mutant Non-Crohn's Disease Adult Recipients Following Intestine Transplantation. Transplant Direct 2020; 6:e556. [PMID: 32607422 PMCID: PMC7266359 DOI: 10.1097/txd.0000000000001006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/13/2020] [Accepted: 04/14/2020] [Indexed: 11/26/2022] Open
Abstract
Despite improved outcomes in the modern era of targeted immunotherapy, intestinal failure and chronic parenteral nutrition remains a significant burden for patients with Crohn’s disease (CD) worldwide. Transplantation is a key component of management when a patient with CD suffers from life-threatening complications of parenteral nutrition. Nucleotide-binding oligomerization domain 2 (NOD2) mutation is a risk factor for both development of CD and intestinal allograft rejection.
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11
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Elsabbagh AM, Hawksworth J, Khan KM, Kaufman SS, Yazigi NA, Kroemer A, Smith C, Fishbein TM, Matsumoto CS. Long-term survival in visceral transplant recipients in the new era: A single-center experience. Am J Transplant 2019; 19:2077-2091. [PMID: 30672105 PMCID: PMC6591067 DOI: 10.1111/ajt.15269] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 12/31/2018] [Accepted: 01/14/2019] [Indexed: 02/06/2023]
Abstract
There is a paucity of data on long-term outcomes following visceral transplantation in the contemporary era. This is a single-center retrospective analysis of all visceral allograft recipients who underwent transplant between November 2003 and December 2013 with at least 3-year follow-up data. Clinical data from a prospectively maintained database were used to assess outcomes including patient and graft survival. Of 174 recipients, 90 were adults and 84 were pediatric patients. Types of visceral transplants were isolated intestinal transplant (56.3%), combined liver-intestinal transplant (25.3%), multivisceral transplant (16.1%), and modified multivisceral transplant (2.3%). Three-, 5-, and 10-year overall patient survival was 69.5%, 66%, and 63%, respectively, while 3-, 5-, and 10-year overall graft survival was 67%, 62%, and 61%, respectively. In multivariable analysis, significant predictors of survival included pediatric recipient (P = .001), donor/recipient weight ratio <0.9 (P = .008), no episodes of severe acute rejection (P = .021), cold ischemia time <8 hours (P = .014), and shorter hospital stay (P = .0001). In conclusion, visceral transplantation remains a good option for treatment of end-stage intestinal failure with parenteral nutritional complications. Proper graft selection, shorter cold ischemia time, and improvement of immunosuppression regimens could significantly improve the long-term survival.
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Affiliation(s)
- Ahmed M. Elsabbagh
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC,Gastroenterology Surgical Center, Department of Surgery, Mansoura University, Mansoura, Egypt,St. Vincent Abdominal Transplant Center, St. Vincent Hospital, Indianapolis, Indiana
| | - Jason Hawksworth
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC,Department of Surgery, Organ Transplant Service, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Khalid M. Khan
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Stuart S. Kaufman
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Nada A. Yazigi
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Alexander Kroemer
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Coleman Smith
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Thomas M. Fishbein
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Cal S. Matsumoto
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
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12
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Intestinal re-transplantation: indications, techniques and outcomes. Curr Opin Organ Transplant 2019; 23:224-228. [PMID: 29465439 DOI: 10.1097/mot.0000000000000515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The field of intestinal transplantation has shown significant growth and has become the gold standard therapy for patients that suffer from the complications of total parenteral nutrition due to irreversible intestinal failure. In the early years of intestinal transplant, retransplantation was associated with extremely high morbidity and mortality. The purpose of this review is to summarize recent encouraging reports, showing significant improvement in outcomes after intestinal retransplantation. RECENT FINDINGS Recent studies at large volume centers have reported significant progress in patient and graft survival after intestinal retransplantation. Recent literature described the most common indications for retransplantation, surgical techniques, timing of graft enterectomy, immunologic monitoring, and complications. Improvement in outcomes due to advances in immunosuppression management and the importance of liver-containing grafts are also described. SUMMARY Improving early to midterm patient and graft survival has made consideration for intestinal retransplantation even more necessary. Current clinical evidence supports the benefit of intestinal retransplantation in well selected recipients. Initial immunosuppression protocols, technical modifications, proper timing of enterectomy, and improved infectious disease monitoring have contributed to improved outcomes.
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13
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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]
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14
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Sullivan HC, Dean CL, Liwski RS, Biswas S, Goodman AL, Krummey S, Gebel HM, Bray RA. (F)Utility of the physical crossmatch for living donor evaluations in the age of the virtual crossmatch. Hum Immunol 2018; 79:711-715. [PMID: 30081064 DOI: 10.1016/j.humimm.2018.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 07/23/2018] [Accepted: 08/02/2018] [Indexed: 12/12/2022]
Abstract
Flow cytometric crossmatches (FCXM) are routinely performed to support living-donor renal transplantation. While long a laboratory mainstay, a physical crossmatch is costly, time consuming, and frequently poses interpretative conundrums with both false-positive and false- negative results. Given the increased utilization of the virtual crossmatch (vXM) in the deceased donor setting, our aim was to assess its utility in living donor evaluations. We reviewed 100 living donor FCXMs and retrospectively performed a vXM for each pair. Seventy-five (75) cases were concordant, (i.e., FCXM-/vXM- or FCXM+/vXM+) while 25 cases were discordant; Five were vXM+/FCXM- and 20 were FCXM+/vXM-. Since donor-specific antibodies (DSA) were not detected in the 20 FCXM+/vXM- cases, these were interpreted as false-positive, i.e., due to non-HLA antibodies. Importantly, none of these patients, when transplanted across a positive FCXM, experienced early antibody mediated rejection or subsequently developed HLA DSA. These data reveal that, for the vast majority of living donor evaluations, a vXM is an acceptable vetting procedure.
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Affiliation(s)
- Harold C Sullivan
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA.
| | - Christina L Dean
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Robert S Liwski
- Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Shilpee Biswas
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Abigail L Goodman
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Scott Krummey
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Howard M Gebel
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Robert A Bray
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA
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Celik N, Stanley K, Rudolph J, Al-Issa F, Kosmach B, Ashokkumar C, Sun Q, Brown-Bakewell R, Zecca D, Soltys K, Khanna A, Bond G, Ganoza A, Mazariegos G, Sindhi R. Improvements in intestine transplantation. Semin Pediatr Surg 2018; 27:267-272. [PMID: 30342602 DOI: 10.1053/j.sempedsurg.2018.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Transplantation of the intestine in children has presented significant challenges even as it has become a standard to treat nutritional failure due to short gut syndrome. These challenges have been addressed in part by significant improvements in short and long-term care. Noteworthy enhancements include reduced need for intestine transplantation, drug-sparing immunosuppressive regimens, immune monitoring, and improved surveillance and management of PTLD and non-adherence.
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Affiliation(s)
- Neslihan Celik
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Kaitlin Stanley
- Division of Pediatric Hematology/Oncology, Children's Hospital of Pittsburgh of UPMC, USA
| | - Jeff Rudolph
- Intestinal Care and Rehabilitation Center, Children's Hospital of Pittsburgh of UPMC, USA
| | - Feras Al-Issa
- Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh of UPMC, USA
| | - Beverly Kosmach
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Chethan Ashokkumar
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Qing Sun
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Renee Brown-Bakewell
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Dale Zecca
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Kyle Soltys
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Ajai Khanna
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Geoffrey Bond
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Armando Ganoza
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - George Mazariegos
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Rakesh Sindhi
- Thomas E Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA.
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16
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Hawksworth JS, Desai CS, Khan KM, Kaufman SS, Yazigi N, Girlanda R, Kroemer A, Fishbein TM, Matsumoto CS. Visceral transplantation in patients with intestinal-failure associated liver disease: Evolving indications, graft selection, and outcomes. Am J Transplant 2018; 18:1312-1320. [PMID: 29498797 PMCID: PMC5992069 DOI: 10.1111/ajt.14715] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 12/11/2017] [Accepted: 02/04/2018] [Indexed: 01/25/2023]
Abstract
Intestinal failure (IF)-associated liver disease (IFALD) is widely recognized as a lethal complication of long-term parenteral nutrition. The pathophysiology of IFALD is poorly understood but appears to be multifactorial and related to the inflammatory state in the patient with IF. Visceral transplant for IFALD includes variants of intestine, liver, or combined liver-intestine allografts. Graft selection for an individual patient depends on the etiology of IF, abdominal and vascular anatomy, severity of IFALD, and potential for intestinal rehabilitation. The past decade has witnessed dramatic improvement in the management of IFALD, principally due to improved lipid emulsion formulations and the multidisciplinary care of the patient with IF. As the recognition and treatment of IFALD continue to improve, the requirement of liver-inclusive visceral grafts appears to be decreasing, representing a paradigm shift in the care of the patient with IF. This review highlights the current indications, graft selection, and outcomes of visceral transplantation for IFALD.
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Affiliation(s)
- Jason S. Hawksworth
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA,Walter Reed National Military Medical Center, Department of Surgery, Organ Transplant Service, Bethesda, MD USA
| | - Chirag S. Desai
- University of North Carolina, Department of Surgery, Division of Abdominal Transplant, Chapel Hill, NC USA
| | - Khalid M. Khan
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Stuart S. Kaufman
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Nada Yazigi
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Raffaele Girlanda
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Alexander Kroemer
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Thomas M. Fishbein
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Cal S. Matsumoto
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
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Abstract
Adult intestinal transplantation differs significantly from pediatric intestinal transplantation. While indications have remained largely consistent since 2000, indications for adults have expanded over the last two decades to include motility disorders and desmoid tumors. Graft type in adult recipients depends on the distinct anatomic characteristics of the adult recipient. Colonic inclusion, while initially speculated to portend unfavorable outcomes due to complex host-bacterial interactions has increased over the past two decades with superior graft survival and improved patient quality of life. Overall, outcomes have steadily improved. For adult intestinal transplant candidates, intestinal transplantation remains a mainstay therapy for complicated intestinal failure and is a promising option for other life threatening and debilitating conditions.
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19
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The impact of antibodies and virtual crossmatching on intestinal transplant outcomes. Curr Opin Organ Transplant 2017; 22:149-154. [DOI: 10.1097/mot.0000000000000393] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Parekh R, Kazimi M, Skorupski S, Fagoaga O, Jafri S, Segovia MC. Intestine Transplantation Across a Positive Crossmatch With Preformed Donor-Specific Antibodies. Transplant Proc 2017; 48:489-91. [PMID: 27109984 DOI: 10.1016/j.transproceed.2015.10.084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 10/21/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND We describe our experience using a modified protocol for immunosuppression for intestine transplantation across a positive crossmatch. Patients who underwent transplantation in 2013 were evaluated over a 12-month period for rejection and infectious events with comparison to procedure-matched controls on our standard protocol of immunosuppression. PATIENTS AND METHODS We used a modified protocol for intestine and multivisceral transplantation for patients with a positive flow crossmatch. In addition to our standard protocol, patients with positive crossmatch were given rituximab and intravenous immunoglobulin (IVIg) preoperatively. DSA was sent for clinical evaluation at monthly intervals. Patients were screened for rejection by endoscopic evaluation. RESULTS Four patients underwent transplantation within a single year across a positive crossmatch. Two received isolated intestine transplants and 2 had multivisceral transplantation (MVT). During the 12-month follow-up, 1 patients had an episode of severe acute cellular rejection, which was managed with increased immunosuppression. None of the patients had episodes of cytomegalovirus infection. One patient developed major infection and 3 patients developed minor bacterial infections. Among procedure-matched controls with negative final crossmatch on standard management (no preoperative rituximab or IVIg), 2 developed mild acute cellular rejection and 2 developed minor infections. One developed cytomegalovirus viremia with invasion to the colonic mucosa. CONCLUSIONS We report our protocol for immunosuppression for IT and MVT across a positive crossmatch. This allowed transplantation despite the presence of a positive crossmatch, with low rejection rates but potentially increased risk for major infections compared to the negative crossmatch controls on our standard protocol.
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Affiliation(s)
- R Parekh
- Department of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan
| | - M Kazimi
- Department of Transplant Surgery, Henry Ford Hospital, Detroit, Michigan
| | - S Skorupski
- Department of Pathology, Henry Ford Hospital, Detroit, Michigan
| | - O Fagoaga
- Department of Pathology, Henry Ford Hospital, Detroit, Michigan
| | - S Jafri
- Department of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan
| | - M C Segovia
- Department of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan.
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21
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Wu GS, Cruz Jr RJ, Cai JC. Acute antibody-mediated rejection after intestinal transplantation. World J Transplant 2016; 6:719-728. [PMID: 28058223 PMCID: PMC5175231 DOI: 10.5500/wjt.v6.i4.719] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 10/02/2016] [Accepted: 11/22/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To investigate the incidence, risk factors and clinical outcomes of acute antibody-mediated rejection (ABMR) after intestinal transplantation (ITx).
METHODS A retrospective single-center analysis was performed to identify cases of acute ABMR after ITx, based on the presence of donor-specific antibody (DSA), acute tissue damage, C4d deposition, and allograft dysfunction.
RESULTS Acute ABMR was identified in 18 (10.3%) out of 175 intestinal allografts with an average occurrence of 10 d (range, 4-162) after ITx. All acute ABMR cases were presensitized to donor human leukocyte antigens class I and/or II antigens with a detectable DSA. A positive cross-match was seen in 14 (77.8%) cases and twelve of 18 patients (66.7%) produced newly-formed DSA following ITx. Histological characteristics of acute ABMR include endothelial C4d deposits, interstitial hemorrhage, and severe congestion with focal fibrin thrombin in the lamina propria capillaries. Multivariate analysis identified a liver-free graft and high level of panel reactive antibody as a significant independent risk factor. Despite initial improvement after therapy, eleven recipients (61.1%) lost transplant secondary to rejection. Of those, 9 (50%) underwent graft removal and 4 (22.2%) received second transplantation following acute ABMR. At an average follow-up of 32.3 mo (range, 13.3-76.4), 8 (44.4%) recipients died.
CONCLUSION Our results indicate that acute ABMR is an important cause of intestine graft dysfunction, particularly in a liver-exclusive graft and survivors are at an increased risk of developing refractory acute rejection and chronic rejection. More effective strategies to prevent and manage acute ABMR are needed to improve outcomes.
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22
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Kroemer A, Cosentino C, Kaiser J, Matsumoto CS, Fishbein TM. Intestinal Transplant Inflammation: the Third Inflammatory Bowel Disease. Curr Gastroenterol Rep 2016; 18:56. [PMID: 27645751 DOI: 10.1007/s11894-016-0530-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Intestinal transplantation is the most immunologically complex of all abdominal organ transplants. Understanding the role both humoral and innate and adaptive cellular immunity play in intestinal transplantation is critical to improving outcomes and increasing indications for patients suffering from intestinal failure. Recent findings highlighting the impact of donor-specific antibodies on intestinal allografts, the role of NOD2 as a key regulator of intestinal immunity, the protective effects of innate lymphoid cells, and the role of Th17 in acute cellular rejection are reviewed here.
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Affiliation(s)
- Alexander Kroemer
- MedStar Georgetown Transplant Institute, 2PHC, Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC, 20007, USA.
| | - Christopher Cosentino
- MedStar Georgetown Transplant Institute, 2PHC, Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC, 20007, USA
| | - Jason Kaiser
- MedStar Georgetown Transplant Institute, 2PHC, Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC, 20007, USA
| | - Cal S Matsumoto
- MedStar Georgetown Transplant Institute, 2PHC, Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC, 20007, USA
| | - Thomas M Fishbein
- MedStar Georgetown Transplant Institute, 2PHC, Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC, 20007, USA
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23
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McCaughan JA, Robertson V, Falconer SJ, Cryer C, Turner DM, Oniscu GC. Preformed donor-specific HLA antibodies are associated with increased risk of early mortality after liver transplantation. Clin Transplant 2016; 30:1538-1544. [DOI: 10.1111/ctr.12851] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2016] [Indexed: 01/15/2023]
Affiliation(s)
- Jennifer A. McCaughan
- Histocompatibility and Immunogenetics Laboratory; Royal Infirmary of Edinburgh; Edinburgh UK
| | - Victoria Robertson
- Histocompatibility and Immunogenetics Laboratory; Royal Infirmary of Edinburgh; Edinburgh UK
| | - Stuart J. Falconer
- Scottish Liver Transplant Unit; Royal Infirmary of Edinburgh; Edinburgh UK
| | - Claire Cryer
- Histocompatibility and Immunogenetics Laboratory; Royal Infirmary of Edinburgh; Edinburgh UK
| | - David M. Turner
- Histocompatibility and Immunogenetics Laboratory; Royal Infirmary of Edinburgh; Edinburgh UK
| | - Gabriel C. Oniscu
- Scottish Liver Transplant Unit; Royal Infirmary of Edinburgh; Edinburgh UK
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24
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Wu GS. Updates on antibody-mediated rejection in intestinal transplantation. World J Transplant 2016; 6:564-572. [PMID: 27683635 PMCID: PMC5036126 DOI: 10.5500/wjt.v6.i3.564] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 06/26/2016] [Accepted: 08/18/2016] [Indexed: 02/05/2023] Open
Abstract
Antibody-mediated rejection (ABMR) has increasingly emerged as an important cause of allograft loss after intestinal transplantation (ITx). Compelling evidence indicates that donor-specific antibodies can mediate and promote acute and chronic rejection after ITx. However, diagnostic criteria for ABMR after ITx have not been established yet and the mechanisms of antibody-mediated graft injury are not well-known. Effective approaches to prevent and treat ABMR are required to improve long-term outcomes of intestine recipients. Clearly, ABMR after ITx has become an important area for research and clinical investigation.
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25
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Abstract
Intestinal transplantation (IT) is the least common form of organ transplantation; however, it has shown exceptional growth and improvement in graft survival rates over the past two decades mainly due to better outcomes achieved during the first year of transplantation (76 % at 1 year), due to improvement in surgical techniques and the development of better immunosupressive therapies as we understand more about the relationship between the recipient and host immune system. There are still ongoing issues with chronic rejection and long-term survival. Intestinal transplantation is still an acceptable therapy for patients with intestinal failure (IF), but it is generally reserved for patients who develop severe and life-threatening complications despite standard therapies, or those who are not able to maintain a good quality of life. The purpose of this review is to describe the current status, indications, outcomes and advances in the field of intestinal transplantation.
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26
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27
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Baxter-Lowe LA, Kucheryavaya A, Tyan D, Reinsmoen N. CPRA for allocation of kidneys in the US: More candidates ≥98% CPRA, lower positive crossmatch rates and improved transplant rates for sensitized patients. Hum Immunol 2016; 77:395-402. [PMID: 27012168 DOI: 10.1016/j.humimm.2016.03.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 03/04/2016] [Accepted: 03/08/2016] [Indexed: 02/06/2023]
Abstract
In 2009 calculated panel reactive antibody (CPRA) replaced PRA as the metric for HLA sensitization in the US kidney allocation system. During the next four years, registrants with at least one unacceptable antigen increased (34-40%) and registrants with ≥98% PRA/CPRA increased from 7% to 9% of the waitlist. These changes were accompanied by a reduction in kidney offers refused for positive crossmatch: 14,137 (1.7%) in 2009 and 3,310 in 2013 (0.4%). Registrants with ≥98% PRA/CPRA had highest rates of refusal but also showed substantial improvement (20% in 2009 vs 8% in 2013). For registrants with ≥98% PRA/CPRA, 45% of accepted offers in 2009 were not transplanted into the intended recipient compared to 11% in 2013. Transplant rates remained low for these patients (∼50/1000 active patient-years), but rates improved for patients with 80-97% PRA/CPRA (223/1000 active patient-years in 2009 vs 354/1000 in 2013). In 2013, 40% regraft candidates had CPRA ≥98% compared to 4% of primary graft candidates. More females than males were ≥98% CPRA (14% vs 7%) and more females had CPRA above 0 (50% vs 28%). In the CPRA era, listing of unacceptable antigens increased, positive crossmatches were diminished and transplant rates for sensitized patients improved.
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Affiliation(s)
- Lee Ann Baxter-Lowe
- Children's Hospital Los Angeles and University of Southern California, Los Angeles, CA, United States.
| | | | - Dolly Tyan
- Stanford University, Palo Alto, CA, United States
| | - Nancy Reinsmoen
- Cedars-Sinai and University of California Los Angeles, Los Angeles, CA, United States
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28
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Garcia-Roca R, Tzvetanov IG, Jeon H, Hetterman E, Oberholzer J, Benedetti E. Successful living donor intestinal transplantation in cross-match positive recipients: Initial experience. World J Gastrointest Surg 2016; 8:101-105. [PMID: 26843919 PMCID: PMC4724584 DOI: 10.4240/wjgs.v8.i1.101] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 08/18/2015] [Accepted: 09/16/2015] [Indexed: 02/06/2023] Open
Abstract
Sensitized patients tend to have longer waiting times on the deceased donor list and are at increased risk of graft loss from acute or chronic rejection compared to non-sensitized candidates. Desensitization protocols are utilized to decrease the levels of alloantibodies and to convert an initial positive cross-match to prospective donors into a negative crossmatch. These procedures are mostly available in the setting of living donation. Due to the elective nature of the procedure, desensitization protocols can be extended until the desire result is obtained prior to transplantation. We present two cases of successful desensitization protocol applied to living donor intestinal transplant candidates that converted to negative cross-match to their donors. We present two cases of intestinal transplant candidates with a potential living donor to whom they are sensitized. Both cases underwent successful transplantation after desensitization protocol. No evidence of humoral rejection has occurred in either recipient. Living donor intestinal transplantation in sensitized recipients against the prospective donors provides the ability to implement a desensitization protocol to convert to negative cross-match.
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29
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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.
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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,
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30
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Donor-specific human leukocyte antigen antibodies in intestinal transplantation. Curr Opin Organ Transplant 2014; 19:261-6. [PMID: 24811437 DOI: 10.1097/mot.0000000000000078] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Early outcomes following intestinal transplantation (ITx) have markedly improved in recent years. However, there has been a lack of improvement in long-term outcomes. Increasing amounts of data suggest the humoral immune system is a major contributor to rejection and late allograft loss. This review will summarize the available data on donor-specific human leukocyte antigen antibodies (DSAs) in ITx, with a focus on the clinical significance of DSAs, diagnosis of antibody-mediated rejection (AMR), and available treatment modalities. Areas requiring further investigation will also be identified. RECENT FINDINGS Mounting evidence shows that pre- and/or posttransplant DSAs are associated with rejection and allograft loss following ITx. Preformed DSAs are present in nearly one-third of ITx recipients, and de-novo DSAs develop in up to 40% of patients. Diagnosis and treatment of AMR remains challenging, but reports indicate that when optimal induction and maintenance immunosuppressive agents are used, the impact of DSAs may be negligible. SUMMARY Although data are limited due to center differences with regard to patient population, induction and maintenance immunosuppression protocols, and monitoring strategies, DSAs are associated with poor outcomes following ITx. A consensus to define AMR and optimal treatment strategies is needed.
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31
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Mercer DF, Iverson AK, Culwell KA. Nutrition and Small Bowel Transplantation. Nutr Clin Pract 2014; 29:615-20. [DOI: 10.1177/0884533614539354] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- David F. Mercer
- Division of Transplantation, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Angie K. Iverson
- Department of Pharmaceutical and Nutrition Care, Nebraska Medical Center, Omaha, Nebraska
| | - Karley A. Culwell
- Department of Pharmaceutical and Nutrition Care, Nebraska Medical Center, Omaha, Nebraska
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Hibi T, Shinoda M, Itano O, Kitagawa Y. Current status of the organ replacement approach for malignancies and an overture for organ bioengineering and regenerative medicine. Organogenesis 2014; 10:241-9. [PMID: 24836922 DOI: 10.4161/org.29245] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Significant achievements in the organ replacement approach for malignancies over the last 2 decades opened new horizons, and the age of "Transplant Oncology" has dawned. The indications of liver transplantation for malignancies have been carefully expanded by a strict patient selection to assure comparable outcomes with non-malignant diseases. Currently, the Milan criteria, gold standard for hepatocellular carcinoma, are being challenged by high-volume centers worldwide. Neoadjuvant chemoradiation therapy and liver transplantation for unresectable hilar cholangiocarcinoma has been successful in specialized institutions. For other primary and metastatic liver tumors, clinical evidence to establish standardized criteria is lacking. Intestinal and multivisceral transplantation is an option for low-grade neoplasms deemed unresectable by conventional surgery. However, the procedure itself is in the adolescent stage. Solid organ transplantation for malignancies inevitably suffers from "triple distress," i.e., oncological, immunological, and technical. Organ bioengineering and regenerative medicine should serve as the "triple threat" therapy and revolutionize "Transplant Oncology."
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Affiliation(s)
- Taizo Hibi
- Department of Surgery; Keio University School of Medicine; Tokyo, Japan
| | - Masahiro Shinoda
- Department of Surgery; Keio University School of Medicine; Tokyo, Japan
| | - Osamu Itano
- Department of Surgery; Keio University School of Medicine; Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery; Keio University School of Medicine; Tokyo, Japan
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33
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Affiliation(s)
- Kishore R. Iyer
- Adult and Pediatric Intestinal Transplant & Rehabilitation Program, Mount Sinai Medical Center, New York, New York
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34
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an update of recent advances in the areas of short bowel syndrome (SBS) and small bowel transplantation (SBT). RECENT FINDINGS Recent reports from two of the largest multicenter randomized, controlled trials in patients with SBS support the safety and efficacy of teduglutide as an aid to parenteral nutrition weaning. In well selected SBS patients, outcomes as diverse as survival, macronutrient absorption and parenteral nutrition weaning are improved after autologous gastrointestinal reconstructive surgery. SBT is no longer considered investigational and given improved outcomes noted in recent reports, indications for transplantation are expanding. Although SBT early survival rates are approaching those of other organ allografts, long-term graft survival remains suboptimal. SUMMARY Recently available trophic factors hold promise as aids in restoring freedom from parenteral nutrition support; however, their long-term benefits, preferred timing of administration in relation to the onset of SBS, optimal patient selection for use, duration of treatment and cost effectiveness require further study. Despite recent evidence of improved early survival after SBT, more dedicated research is needed to design more effective strategies to better tolerize small bowel grafts, prevent rejection and, ultimately, improve long-term outcomes. Reserved for well selected patients, autologous gastrointestinal reconstruction should be considered complementary and not antagonistic to SBT.
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Clinical relevance of human leukocyte antigen antibodies in liver, heart, lung and intestine transplantation. Curr Opin Organ Transplant 2013; 18:463-9. [PMID: 23838652 DOI: 10.1097/mot.0b013e3283636c71] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW Solid phase assays identify human leukocyte antigen (HLA) antibodies with a great sensitivity. Whether to accept or decline an organ if the virtual crossmatch is positive, when to monitor and whether to treat de-novo donor-specific antibody (DSA) posttransplant remain challenging issues for the transplant clinician. RECENT FINDINGS Technologies that can differentiate which antibodies pose the greatest risk for antibody-mediated rejection (AMR) are evolving. Complement fixing luminex assays have been used to predict high-risk antibodies, but using these assays alone will miss some preformed antibodies. How these technologies fit into the laboratory's testing algorithm will likely need to be individualized. Posttransplant de-novo DSAs are associated with inferior outcomes. In hearts, similar to renal transplantation, acute rejection is a risk factor for developing de-novo DSA. Further data are needed to determine whether other risk factors are similar to those reported for renal transplants. Antibodies to self-antigens are increasingly recognized posttransplant and how the alloimmune response contributes to altered autoregulation is a current research focus. SUMMARY Identification of DSA enables the clinician to make informed decisions regarding whether or not to accept an organ and if augmented immunosuppression is indicated. Monitoring for DSA posttransplant identifies recipients at a greater risk for AMR and can guide management. However, the best approach to dealing with de-novo DSA remains unclear.
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