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Assadiasl S, Nicknam MH. Intestinal transplantation: Significance of immune responses. Arab J Gastroenterol 2024:S1687-1979(24)00079-0. [PMID: 39289083 DOI: 10.1016/j.ajg.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 07/06/2024] [Accepted: 08/02/2024] [Indexed: 09/19/2024]
Abstract
Intestinal allografts, with many resident immune cells and as a destination for circulating lymphocytes of the recipient, appear to be the most challenging solid organ transplants. The high incidence of acute rejection and frequent reports of fatal graft-versus-host disease (GvHD) after intestinal transplantation call for more research to describe the molecular mechanisms involved in the immunopathogenesis of post-transplant complications to define new therapeutic targets. In addition, according to the rapid development of immunosuppressive agents, it is time to consider novel therapeutic approaches in managing treatment-refractory patients with rejection or severe GvHD. Herein, the main immunological challenges before and after intestinal transplant including, brain-dead donor inflammation, acute rejection, antibody-mediated, and chronic rejections, as well as GvHD have been described. Besides, the new immune-based therapies used in experimental and clinical settings to improve tolerance toward intestinal allograft, and cases of operational tolerance have been reviewed.
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Affiliation(s)
- Sara Assadiasl
- Molecular Immunology Research Center, Tehran University of Medical Sciences, Tehran, Iran; Iranian Tissue Bank and Research Center, Tehran University of Medical Science, Tehran, Iran.
| | - Mohammad Hossein Nicknam
- Molecular Immunology Research Center, Tehran University of Medical Sciences, Tehran, Iran; Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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2
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Karmi N, Uniken Venema WTC, van der Heide F, Festen EAM, Dijkstra G. Biologicals in the prevention and treatment of intestinal graft rejection: The state of the art Biologicals in Intestinal Transplantation. Hum Immunol 2024; 85:110810. [PMID: 38788483 DOI: 10.1016/j.humimm.2024.110810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 04/10/2024] [Accepted: 05/01/2024] [Indexed: 05/26/2024]
Abstract
Intestinal transplantation is the standard treatment for patients with intestinal failure with severe complications due to parenteral nutrition; however, rejection leads to graft failure in approximately half of both adult and pediatric recipients within 5 years of transplantation. Although intensive immunosuppressive therapy is used in an attempt to reduce this risk, commonly used treatment strategies are generally practice- and/or expert-based, as head-to-head comparisons are lacking. In this ever-developing field, biologicals designed to prevent or treat rejection are used increasingly, with both infliximab and vedolizumab showing potential in the treatment of acute cellular rejection in individual cases and in relatively small patient cohorts. To help advance progress in clinical care, we review the current use of biologicals in intestinal transplantation, and we provide future perspectives to guide this progress.
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Affiliation(s)
- Naomi Karmi
- University of Groningen, University Medical Center Groningen, Department of Gastroenterology and Hepatology, Groningen, The Netherlands
| | - Werna T C Uniken Venema
- University of Groningen, University Medical Center Groningen, Department of Gastroenterology and Hepatology, Groningen, The Netherlands
| | - Frans van der Heide
- University of Groningen, University Medical Center Groningen, Department of Gastroenterology and Hepatology, Groningen, The Netherlands
| | - Eleonora A M Festen
- University of Groningen, University Medical Center Groningen, Department of Gastroenterology and Hepatology, Groningen, The Netherlands
| | - Gerard Dijkstra
- University of Groningen, University Medical Center Groningen, Department of Gastroenterology and Hepatology, Groningen, The Netherlands.
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3
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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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Abele D, Gäbel M, Oltean M, Varkey J, Mölne J, Ekwall N, Borg H, Jacobsson H, Holgersson J, Herlenius G. Including the liver in the visceral allograft: Impact on donor-specific anti-HLA antibodies and long-term outcomes. Hum Immunol 2024; 85:110767. [PMID: 38418315 DOI: 10.1016/j.humimm.2024.110767] [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: 12/19/2023] [Revised: 02/07/2024] [Accepted: 02/19/2024] [Indexed: 03/01/2024]
Abstract
Humoral immunity emerges as a risk factor for graft failure after visceral transplantation (VTx) and development of donor-specific anti-HLA antibodies (DSAs) has been linked with poor outcomes. In most cases, a simultaneous liver transplant can be safely performed in sensitized patients with DSA and appears protective against lymphocytotoxic antibodies. We investigated the incidence of acute (AR) and chronic rejection (CR) in 32 VTx without any B cell-depleting pre-treatment (6 isolated intestinal transplants (IT) and 26 liver-containing, multivisceral transplants (MVT) and assessed the presence of donor-specific antibodies (DSA) pre- and post-transplantation. Twenty-one patients (65 %) developed AR, 15 (57 %) of the MVT and 6 (100 %) of the IT (p = 0.05). CR occurred in 4 IT (60 %, p < 0.001). At one month, de novo DSA were present in 71 % of VTx (66 % MVT vs 100 % IT, p = 0.09). At the last available follow-up, 69 % of the MVT and 50 % of the IT patients were DSA-free. De novo DSA seemed more persistent (7/19, 37 %) than pre-Tx DSA (1/6, 17 %; p = n.s.), de novo DSA were more frequently specific for HLA class II than class I, 16/19 (84 %) vs. 7/19 (37 %; p = 0.003), and HLA-DQ was their most frequent target HLA. DQ mismatches appeared to be a risk factor for developing de novo DSA. In conclusion, liver-containing visceral allografts have superior short- and long-term outcomes compared with liver-free allografts. De novo DSA develop early and frequently after VTx performed without B cell-depleting induction therapy, but the exact role of DSA in the pathogenesis of rejection remains unclear.
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Affiliation(s)
- Dace Abele
- Department of Clinical Immunology and Transfusion Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Markus Gäbel
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Mihai Oltean
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.
| | - Jonas Varkey
- Division of Gastroenterology, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Johan Mölne
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Nils Ekwall
- Department of Pediatric Medicine, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy at University of Gothenburgl, Gothenburg, Sweden
| | - Helena Borg
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy at University of Gothenburgl, Gothenburg, Sweden; Department of Pediatric Surgery, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hanna Jacobsson
- Biobank West, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jan Holgersson
- Department of Clinical Immunology and Transfusion Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Gustaf Herlenius
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
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5
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Klein K, Keck M, Langewisch E, Merani S, Hitchman K, Leick M. Evaluation of serial monitoring of donor-specific antibodies in pediatric and adult intestinal/multivisceral transplant recipients. Pediatr Transplant 2024; 28:e14638. [PMID: 37942670 DOI: 10.1111/petr.14638] [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: 06/15/2023] [Revised: 08/23/2023] [Accepted: 10/24/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND The study purpose was to add to limited literature assessing anti-HLA donor-specific antibody (DSA) appearance, clearance, specificity, and impact in intestinal/multivisceral (MV) transplant as well as the value of serial monitoring following an institutional protocol shift implementing serial monitoring. METHODS This single-center retrospective review included intestinal/MV recipients transplanted 1/1/15-9/31/17 with completed DSA testing. Patients were divided into groups based on DSA presence post-transplant. The primary outcome was biopsy-proven acute rejection (BPAR). Secondary outcomes included graft loss and death. Descriptive analysis of DSA was completed. RESULTS Of the 35 intestinal/MV recipients (60% pediatric) with DSA testing, 24 patients had post-transplant DSA. Fifteen patients in the DSA(+) group had T-cell-mediated BPAR versus five in the DSA(-) group (63% vs 45%, p = .47). Days to BPAR were 25 [IQR 19-165] (DSA(+) group) versus 232 [IQR 25.5-632.5] (DSA(-) group) (p = .066). There were no differences between groups for graft loss or death. One hundred and five DSA were identified in the DSA(+) group with 63% being class II, and 54% cleared during follow-up. DSA were directed against 50 different HLA alleles, with the most common being directed against HLA- DQ (35%). Time to first DSA and to clearance did not differ between class I and II. CONCLUSION Findings confirm previous data that suggest post-transplant DSA in this population may lead to increased BPAR or shorter time to BPAR, although not statistically significant. Most DSA were identified within the first month after transplant, and ahead of rejection identification on biopsy. DSA therefore may have utility as an early rejection biomarker and use may be considered in place of early protocol biopsies, particularly in pediatric patients. We identified novel findings of DSA directed against a large breadth of HLA in intestinal/MV patients.
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Affiliation(s)
- Kelsey Klein
- University Health Transplant Institute, San Antonio, Texas, USA
- The University of Texas at Austin, College of Pharmacy, Pharmacotherapy Division, Austin TX, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Megan Keck
- Nebraska Medicine, Omaha, NE, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Eric Langewisch
- Nebraska Medicine, Omaha, NE, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Shaheed Merani
- Nebraska Medicine, Omaha, NE, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Kelley Hitchman
- University Health Transplant Institute, San Antonio, Texas, USA
- Department of Pathology and Laboratory Medicine, UT Health San Antonio, San Antonio, Texas, USA
| | - Mary Leick
- Nebraska Medicine, Omaha, NE, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Karaman Y, Cakmak M, Gunturk S, Aydin G, Guvenli Y. Current Anesthetic Management in a 20-Month-Old Pediatric Patient With Intestinal Transplantation Due to Microvillous Inclusion Disease. EXP CLIN TRANSPLANT 2023; 21:992-995. [PMID: 33663362 DOI: 10.6002/ect.2020.0385] [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: 11/05/2022]
Abstract
Intestinal transplantation is a complex procedure both in terms of anesthesia and surgery. In particular, pediatric anesthesia management during intestinal transplant surgery can become even more complicated. It has been stated that propofol, remifentanil, and sevoflurane reduce patient mortality by reducing the incidence of intestinal ischemiareperfusion injury. Although studies of these agents continue to be conducted in vivo or in vitro, these anesthetics are currently used for specific procedures that have a high risk of incurring ischemia-reperfusion injury. Herein, we present the case of a male child, aged 20 months, who was dependent on total parenteral nutrition and was found to have intestinal failure associated with liver disease type 1. Hematologic tests showed findings of anemia and metabolic acidosis. Propofol was administered for induction of anesthesia. Anesthesia maintenance was achieved using sevoflurane with remifentanil infusion. We ensured safe and adequate vascular access in the patient and performed hematologic and biochemical tests with detailed system controls. Before the procedure, we prepared a leukocyte-poor erythrocyte suspension, leukocyte-poor random or apheresis platelets, and ABO- and Rh-compatible fresh frozen plasma. We monitored for signs of acidosis, hypotension, coagulation disorders, and hyperkalemia during the reperfusion period.We maintained patient normothermia. In this case report on the anesthetic management of a pediatric patient aged 20 months who received a small bowel transplant due to microvillous inclusion disease, we found that the selection of anesthetic agents may affect the prognosis of future surgical procedures.
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Affiliation(s)
- Yucel Karaman
- From the University of Health Sciences, Izmir Tepecik Training and Research Hospital, Department of Anesthesiology and Reanimation, Izmir, Turkey
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Vianna R, Gaynor JJ, Selvaggi G, Farag A, Garcia J, Tekin A, Tabbara MM, Ciancio G. Liver Inclusion Appears to Be Protective Against Graft Loss-Due-to Chronic But Not Acute Rejection Following Intestinal Transplantation. Transpl Int 2023; 36:11568. [PMID: 37779512 PMCID: PMC10538304 DOI: 10.3389/ti.2023.11568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/28/2023] [Indexed: 10/03/2023]
Abstract
In intestinal transplantation, while other centers have shown that liver-including allografts have significantly more favorable graft survival and graft loss-due-to chronic rejection (CHR) rates, our center has consistently shown that modified multivisceral (MMV) and full multivisceral (MV) allografts have significantly more favorable acute cellular rejection (ACR) and severe ACR rates compared with isolated intestine (I) and liver-intestine (LI) allografts. In the attempt to resolve this apparent discrepancy, we performed stepwise Cox multivariable analyses of the hazard rates of developing graft loss-due-to acute rejection (AR) vs. CHR among 350 consecutive intestinal transplants at our center with long-term follow-up (median: 13.5 years post-transplant). Observed percentages developing graft loss-due-to AR and CHR were 14.3% (50/350) and 6.6% (23/350), respectively. Only one baseline variable was selected into the Cox model indicating a significantly lower hazard rate of developing graft loss-due-to AR: Transplant Type MMV or MV (p < 0.000001). Conversely, two baseline variables were selected into the Cox model indicating a significantly lower hazard rate of developing graft loss-due-to CHR: Received Donor Liver (LI or MV) (p = 0.002) and Received Induction (p = 0.007). In summary, while MMV/MV transplants (who receive extensive native lymphoid tissue removal) offered protection against graft loss-due-to AR, liver-containing grafts appeared to offer protection against graft loss-due-to CHR, supporting the results of other studies.
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Affiliation(s)
- Rodrigo Vianna
- Department of Surgery, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Jeffrey J. Gaynor
- Department of Surgery, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Gennaro Selvaggi
- Department of Surgery, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Ahmed Farag
- Department of Surgery, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
- Department of Surgery, Zagazig University School of Medicine, Zagazig, Egypt
| | - Jennifer Garcia
- Department of Pediatrics, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Akin Tekin
- Department of Surgery, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Marina M. Tabbara
- Department of Surgery, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Gaetano Ciancio
- Department of Surgery, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
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8
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Gaynor JJ, Tabbara MM, Ciancio G, Selvaggi G, Garcia J, Tekin A, Vianna R. The Importance Of Avoiding Time-Dependent Bias When Testing The Prognostic Value Of An Intervening Event - Two Acute Cellular Rejection Examples In Intestinal Transplantation. Am J Transplant 2023:S1600-6135(23)00308-8. [PMID: 36871628 DOI: 10.1016/j.ajt.2023.02.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/24/2023] [Indexed: 03/07/2023]
Abstract
In testing the prognostic value of the occurrence of an intervening event (clinical event that occurs post-transplant), 3 proper statistical methodologies for testing its prognostic value exist (time dependent covariate, landmark, and semi-Markov modelling methods). However, time-dependent bias has appeared in many clinical reports, whereby the intervening event is statistically treated as a baseline variable (as if it occurred at transplant). Using a single-center cohort of 445 intestinal transplant cases to test the prognostic value of 1st acute cellular rejection (ACR) and severe (grade of) ACR on the hazard rate of developing graft loss, we demonstrate how the inclusion of such time-dependent bias can lead to severe underestimation of the true hazard ratio (HR). The (statistically more powerful) time dependent covariate method in Cox's multivariable model yielded significantly unfavorable effects of 1st ACR (P<.0001; HR=2.492) and severe ACR (P<.0001; HR=4.531). In contrast, when using the time-dependent biased approach, multivariable analysis yielded an incorrect conclusion for the prognostic value of 1st ACR (P=.31, HR=0.877, 35.2% of 2.492) and a much smaller estimated effect of severe ACR (P=.0008; HR=1.589; 35.1% of 4.531). In conclusion, this study demonstrates the importance of avoiding time-dependent bias when testing the prognostic value of an intervening event.
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Affiliation(s)
- Jeffrey J Gaynor
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL.
| | - Marina M Tabbara
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Gaetano Ciancio
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Gennaro Selvaggi
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Jennifer Garcia
- Miami Transplant Institute, Department of Pediatrics, University of Miami Miller School of Medicine; Miami, FL
| | - Akin Tekin
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Rodrigo Vianna
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
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Lasa-Lázaro M, Ramos-Boluda E, Mancebo E, Castro-Panete MJ, González-Sacristán R, Serradilla J, Andrés-Moreno AM, Hernández-Oliveros F, Paz-Artal E, Talayero P. Antibody-removal therapies for de novo DSA in pediatric intestinal recipients: Why, when, and how? A single-center experience. Front Pediatr 2022; 10:1074577. [PMID: 36819192 PMCID: PMC9932897 DOI: 10.3389/fped.2022.1074577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 12/21/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Donor-specific anti-HLA antibodies (DSA) impact negatively on the outcome of intestinal grafts. Although the use of antibody-removal therapies (ART) is becoming more frequent in the last few years, issues regarding their timing and effectiveness remain under discussion. METHODS In the present study, we report our experience with eight ART procedures (based on plasmapheresis, intravenous immunoglobulin, and rituximab) in eight pediatric intestinal and multivisceral transplants with de novo DSA (dnDSA). RESULTS ART were performed when dnDSA appeared in two contexts: (1) concomitant with rejection (acute or chronic) or (2) without rejection or any other clinical symptom. Complete DSA removal was observed in seven out of eight patients, showing an effectiveness of 88%. In the group treated for dnDSA without clinical symptoms, the success rate was 100%, with complete DSA removal and without rejection afterward. A shorter time between DSA detection and ART performance appeared as a significant factor for the success of the therapy (p = 0.0002). DSA against HLA-A and DQ alleles were the most resistant to ART, whereas anti-DR DSA were the most sensitive. In addition, the 8-year allograft survival rate in recipients undergoing ART was similar to that in those without DSA, being significantly lower in non-treated DSA-positive recipients (p = 0.013). CONCLUSION The results confirm the effectiveness of ART in terms of DSA removal and allograft survival and encourage its early use even in the absence of clinical symptoms.
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Affiliation(s)
- María Lasa-Lázaro
- Department of Immunology, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Esther Ramos-Boluda
- Unit of Intestinal Rehabilitation and Transplant, University Hospital La Paz, Madrid, Spain
| | - Esther Mancebo
- Department of Immunology, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - María José Castro-Panete
- Department of Immunology, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | | | - Javier Serradilla
- Department of Pediatric Surgery, University Hospital La Paz, Madrid, Spain.,IdiPaz Research Institute, University Hospital La Paz, Madrid, Spain
| | - Ane Miren Andrés-Moreno
- Department of Pediatric Surgery, University Hospital La Paz, Madrid, Spain.,IdiPaz Research Institute, University Hospital La Paz, Madrid, Spain
| | - Francisco Hernández-Oliveros
- Department of Pediatric Surgery, University Hospital La Paz, Madrid, Spain.,IdiPaz Research Institute, University Hospital La Paz, Madrid, Spain
| | - Estela Paz-Artal
- Department of Immunology, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain.,School of Medicine, Complutense University, Madrid, Spain.,CIBER de Enfermedades Infecciosas, ISCIII, Madrid, Spain
| | - Paloma Talayero
- Department of Immunology, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
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10
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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: 9] [Impact Index Per Article: 3.0] [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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11
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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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12
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Courbage S, Canioni D, Talbotec C, Lambe C, Chardot C, Rabant M, Galmiche L, Corcos O, Goulet O, Joly F, Lacaille F. Beyond 10 years, with or without an intestinal graft: Present and future? Am J Transplant 2020; 20:2802-2812. [PMID: 32277553 DOI: 10.1111/ajt.15899] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 03/12/2020] [Accepted: 03/18/2020] [Indexed: 01/25/2023]
Abstract
Long-term outcomes in children undergoing intestinal transplantation remain unclear. Seventy-one children underwent intestinal transplantation in our center from 1989 to 2007. We report on 10-year posttransplant outcomes with (group 1, n = 26) and without (group 2, n = 9) a functional graft. Ten-year patient and graft survival rates were 53% and 36%, respectively. Most patients were studying or working, one third having psychiatric disorders. All patients in group 1 were weaned off parenteral nutrition with mostly normal physical growth and subnormal energy absorption. Graft histology from 15 late biopsies showed minimal abnormality. However, micronutrient deficiencies and fat malabsorption were frequent; biliary complications occurred in 4 patients among the 17 who underwent liver transplantation; median renal clearance was 87 mL/min/1.73 m2 . Four patients in group 1 experienced late acute rejection. Among the 9 patients in group 2, 4 died after 10 years and 2 developed significant liver fibrosis. Liver transplantation and the use of a 3-drug regimen including sirolimus or mycophenolate mofetil were associated with improved graft survival. Therefore, intestinal transplantation may enable a satisfactory digestive function in the long term. The prognosis of graft removal without retransplantation is better than expected. Regular monitoring of micronutrients, early psychological assessment, and use of sirolimus are recommended.
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Affiliation(s)
- Sophie Courbage
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - Danielle Canioni
- Department of Pathology, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - Cécile Talbotec
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - Cécile Lambe
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - Christophe Chardot
- Department of Pediatric Surgery, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - Marion Rabant
- Department of Pathology, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - Louise Galmiche
- Department of Pathology, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - Olivier Corcos
- Department of Gastroenterology, Nutrition Support and Intestinal Transplantation, Beaujon Hospital, University of Paris, Clichy, France
| | - Olivier Goulet
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - Francisca Joly
- Department of Gastroenterology, Nutrition Support and Intestinal Transplantation, Beaujon Hospital, University of Paris, Clichy, France
| | - Florence Lacaille
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Necker-Enfants Malades Hospital, University of Paris, Paris, France
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13
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Raghu VK, Rudolph JA, Jalal HJ, Smith KJ. Microsimulation Model to Compare Enteral and Parenteral Iron Supplementation in Children With Intestinal Failure. JPEN J Parenter Enteral Nutr 2020; 45:810-817. [PMID: 32511770 DOI: 10.1002/jpen.1940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/15/2020] [Accepted: 05/26/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Children with chronic intestinal failure have a high prevalence of anemia, commonly from iron deficiency, leading to frequent blood transfusions. No current guideline exists for iron supplementation in these children. In this analysis, we evaluate the effectiveness and the cost-effectiveness of using parenteral, enteral, and no iron supplementation to reduce blood transfusions. METHODS We created a microsimulation model of pediatric intestinal failure over a 1-year time horizon. Model outcomes included cost (US dollars), blood transfusions received, and hemoglobin trend. Strategies tested included no supplementation, daily enteral supplementation, and monthly parenteral supplementation. We estimated parameters for the model using an institutional cohort of 55 patients. Model parameters updated each 1-month cycle using 2 regressions. A multivariate mixed-effects linear regression estimated hemoglobin values at the next month based on data from the prior month. A mixed-effects logistic regression on hemoglobin predicted the probability of receiving a blood transfusion in a given month. RESULTS Compared with no supplementation, both enteral and parenteral iron supplementation reduced blood transfusions required per patient by 0.3 and 0.5 transfusions per year, respectively. Enteral iron cost $34 per avoided blood transfusion. Parenteral iron cost an additional $6600 per avoided blood transfusion compared with enteral iron. CONCLUSIONS We found both parenteral and enteral iron to be effective at reducing blood transfusions. The cost of enteral iron makes it the desired choice in patients who can tolerate it. Future work should aim to identify which subpopulations of patients may benefit most from one strategy over the other.
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Affiliation(s)
- Vikram Kalathur Raghu
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeffrey A Rudolph
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hawre J Jalal
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kenneth J Smith
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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14
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Yamanashi K, Chen-Yoshikawa TF, Hamaji M, Yurugi K, Tanaka S, Yutaka Y, Yamada Y, Nakajima D, Ohsumi A, Date H. Outcomes of combination therapy including rituximab for antibody-mediated rejection after lung transplantation. Gen Thorac Cardiovasc Surg 2019; 68:142-149. [DOI: 10.1007/s11748-019-01189-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 08/10/2019] [Indexed: 01/03/2023]
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15
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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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16
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Talayero P, Ramos Boluda E, Gómez Massa E, Castro Panete MJ, Prieto Bozano G, Hernández Oliveros F, López Santamaría M, Calvo Pulido J, Paz-Artal E, Mancebo E. Donor-Specific Antibodies in Pediatric Intestinal and Multivisceral Transplantation: The Role of Liver and Human Leukocyte Antigen Mismatching. Liver Transpl 2018; 24:1726-1735. [PMID: 30112820 DOI: 10.1002/lt.25323] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 08/07/2018] [Indexed: 01/13/2023]
Abstract
Rejection is one of the most important drawbacks for graft and patient survival in intestinal and multivisceral transplantation. However, there is no consensus on the diagnostic criteria for humoral rejection, and the literature about the role of donor-specific antibodies (DSA) on allograft outcome and the risk factors that contribute to their development is scant with contradictory results. The present study analyzes the role of DSA exclusively in a pediatric cohort of 43 transplants. Among our patients, 11.6% showed preformed DSA, but they did not correlate with more rejection or less allograft survival. Having previous transplants was the main sensitization factor with an odds ratio (OR) = 44.85 (P = 0.001). In total, 16.3% of recipients developed de novo donor-specific antibodies (dnDSA), mostly directed against human leukocyte antigen (HLA) class II, polyspecific and complement fixing. Additionally, the presence of dnDSA had a deleterious effect on graft rejection (hazard ratio [HR] = 11.00; P = 0.01) and survival (HR = 66.52; P < 0.001) in an observational period of 5 years after transplantation. The inclusion of the liver emerged as the main protective factor against dnDSA development with an OR = 0.07 (P = 0.007). The analysis of HLA compatibility at the serological and epitope level with the computational tools HLAMatchmaker and PIRCHE revealed no association between HLA mismatching and dnDSA. In conclusion, this study performed in pediatric recipients shows the deleterious effect of dnDSA on intestinal transplantation supported by the complement-fixing activity observed. Additionally, the liver inclusion in the allografts showed to be a protective factor against dnDSA generation.
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Affiliation(s)
- Paloma Talayero
- Department of Immunology, University Hospital 12 de Octubre, Madrid, Spain.,I+12 Research Institute, University Hospital 12 de Octubre, Madrid, Spain
| | - Esther Ramos Boluda
- Pediatric Gastroenterology Intestinal Rehabilitation Unit, University Hospital La Paz, Madrid, Spain
| | - Elena Gómez Massa
- Department of Immunology, University Hospital 12 de Octubre, Madrid, Spain.,I+12 Research Institute, University Hospital 12 de Octubre, Madrid, Spain
| | | | - Gerardo Prieto Bozano
- Pediatric Gastroenterology Intestinal Rehabilitation Unit, University Hospital La Paz, Madrid, Spain
| | - Francisco Hernández Oliveros
- Department of Pediatric Surgery, University Hospital La Paz, Madrid, Spain.,EOC of ERN-Transplantchild, University Hospital La Paz, Madrid, Spain
| | | | - Jorge Calvo Pulido
- General and Digestive Surgery and Abdominal Organ Transplantation, University Hospital 12 de Octubre, Madrid, Spain.,School of Medicine, Complutense University, Madrid, Spain
| | - Estela Paz-Artal
- Department of Immunology, University Hospital 12 de Octubre, Madrid, Spain.,I+12 Research Institute, University Hospital 12 de Octubre, Madrid, Spain.,School of Medicine, Complutense University, Madrid, Spain.,Section of Immunology, San Pablo CEU University, Madrid, Spain
| | - Esther Mancebo
- Department of Immunology, University Hospital 12 de Octubre, Madrid, Spain.,I+12 Research Institute, University Hospital 12 de Octubre, Madrid, Spain.,School of Medicine, Complutense University, Madrid, Spain
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17
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Rabant M, Racapé M, Petit LM, Taupin JL, Aubert O, Bruneau J, Barbet P, Goulet O, Chardot C, Suberbielle C, Lacaille F, Canioni D, Duong Van Huyen JP. Antibody-mediated rejection in pediatric small bowel transplantation: Capillaritis is a major determinant of C4d positivity in intestinal transplant biopsies. Am J Transplant 2018; 18:2250-2260. [PMID: 29397036 DOI: 10.1111/ajt.14685] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 12/21/2017] [Accepted: 01/24/2018] [Indexed: 01/25/2023]
Abstract
The diagnostic criteria for antibody-mediated rejection (ABMR) after small bowel transplantation (SBT) are not clearly defined, although the presence of donor-specific antibodies (DSAs) has been reported to be deleterious for graft survival. We aimed to determine the incidence and prognostic value of DSAs and C4d in pediatric SBT and to identify the histopathologic features associated with C4d positivity. We studied all intestinal biopsies (IBx) obtained in the first year posttransplantation (N = 345) in a prospective cohort of 23 children. DSAs and their capacity to fix C1q were identified by using Luminex technology. Eighteen patients (78%) had DSAs, and 9 had the capacity to fix C1q. Seventy-eight IBx (22.6%) were C4d positive. The independent determinants of C4d positivity were capillaritis grades 2 and 3 (odds ratio [OR] 4.02, P = .047 and OR 5.17, P = .003, respectively), mucosal erosion/ulceration (OR 2.8, P = .019), lamina propria inflammation grades 1 and 2/3 (OR 1.95, P = .043 and OR 3.1, P = .016, respectively), and chorion edema (OR 2.16, P = .028). Complement-fixing DSAs and repeated C4d-positive IBx were associated with poor outcome (P = .021 and P = .001, respectively). Our results support that capillaritis should be considered as a feature of ABMR in SBT and identify C1q-fixing DSAs and repeated C4d positivity as potential markers of poor outcome.
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Affiliation(s)
- Marion Rabant
- Pathology Department, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France.,INSERM U1151, Hôpital Necker, Paris, France.,Paris V Descartes University, Sorbonne-Paris-Cité, Paris, France
| | - Maud Racapé
- Paris Translational Research for Organ Transplant INSERM U 970, PARCC, HEGP, Paris, France
| | - Laetitia-Marie Petit
- Pediatric Gastroenterology Department, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jean Luc Taupin
- Immunology and histocompatibility laboratory, Saint Louis Hospital, Paris, France
| | - Olivier Aubert
- Paris Translational Research for Organ Transplant INSERM U 970, PARCC, HEGP, Paris, France
| | - Julie Bruneau
- Pathology Department, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris V Descartes University, Sorbonne-Paris-Cité, Paris, France
| | - Patrick Barbet
- Pathology Department, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris V Descartes University, Sorbonne-Paris-Cité, Paris, France
| | - Olivier Goulet
- Paris V Descartes University, Sorbonne-Paris-Cité, Paris, France.,Pediatric Gastroenterology Department, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Christophe Chardot
- Paris V Descartes University, Sorbonne-Paris-Cité, Paris, France.,Pediatric Surgery Department, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Caroline Suberbielle
- Immunology and histocompatibility laboratory, Saint Louis Hospital, Paris, France
| | - Florence Lacaille
- Pediatric Gastroenterology Department, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Danielle Canioni
- Pathology Department, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris V Descartes University, Sorbonne-Paris-Cité, Paris, France
| | - Jean-Paul Duong Van Huyen
- Pathology Department, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris V Descartes University, Sorbonne-Paris-Cité, Paris, France.,Paris Translational Research for Organ Transplant INSERM U 970, PARCC, HEGP, Paris, France
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18
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Lauro A, Oltean M, Marino IR. Chronic Rejection After Intestinal Transplant: Where Are We in Order to Avert It? Dig Dis Sci 2018; 63:551-562. [PMID: 29327261 DOI: 10.1007/s10620-018-4909-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 01/02/2018] [Indexed: 12/18/2022]
Abstract
Chronic rejection affects the long-term survival of all solid organ transplants and, among intestinal allografts, occurs in up to 10% of the recipients. The insidious clinical evolution of the chronic allograft enteropathy, the absence of noninvasive biomarkers, and the late endoscopic findings delay its diagnosis. No pharmacological approach has been proven effective, and allograft removal nowadays still represents the only available therapy. The inclusion of the liver in the visceral allograft appears to be the only intervention affecting the development of chronic rejection, as revealed by large-center studies and registry reports. A significant body of evidence emerged from the experimental setting and provided essential knowledge on the complex mechanisms behind the development of chronic allograft enteropathy. More recently, donor-specific antibodies have been suggested as an early, key element in the natural history of chronic allograft enteropathy and several novel approaches, tackling the antibody-mediated graft injury, have gained acceptance in clinical settings and are believed to impact on chronic rejection. The inclusion of a liver allograft is advocated when re-transplanting a sensitized recipient, due to its protective effect against humoral immunity. Multicenter trials are required to understand and tackle chronic rejection, and find the therapeutic answer to this clinical dilemma.
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Affiliation(s)
- Augusto Lauro
- Liver and Multiorgan Transplant Unit, St. Orsola University Hospital, Alma Mater Studiorum, Bologna, Italy.
| | - Mihai Oltean
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ignazio R Marino
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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19
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Abstract
PURPOSE OF REVIEW The purpose of this article is to review the existing literature on the current indications, surgical techniques, immunosuppressive therapy and outcomes following intestinal transplantation (ITx). RECENT FINDINGS Over recent years, ITx has become a more common operation with approximately 2500 procedures carried out worldwide by 2014. It is reserved for patients with intestinal failure and who have developed complications of home parenteral nutrition or who have a high risk of dying from their underlying disease. Recent advances such as the improvement in survival rates, not only for isolated small bowel transplants but also following inclusion of a liver graft in combined liver-small bowel transplant, and the utility of citrulline as a noninvasive biomarker to appreciate acute rejection herald an exciting shift in the field of ITx. SUMMARY With advancements in immunosuppressive drugs, induction regimens, standardization of surgical techniques and improved postoperative care, survival is increasing. In due course, it will most likely become as good as remaining on home parenteral nutrition and as such could become a viable first-line option.
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20
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Lacaille F, Irtan S, Dupic L, Talbotec C, Lesage F, Colomb V, Salvi N, Moulin F, Sauvat F, Aigrain Y, Revillon Y, Goulet O, Chardot C. Twenty-eight years of intestinal transplantation in Paris: experience of the oldest European center. Transpl Int 2017; 30:178-186. [DOI: 10.1111/tri.12894] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 10/31/2016] [Accepted: 11/20/2016] [Indexed: 01/19/2023]
Affiliation(s)
- Florence Lacaille
- Pediatric Gastroenterology-Hepatology-Nutrition; Necker-Enfants malades Hospital; Paris France
| | - Sabine Irtan
- Pediatric Surgery; Necker-Enfants malades Hospital; Paris France
| | - Laurent Dupic
- Pediatric Intensive Care; Necker-Enfants malades Hospital; Paris France
| | - Cécile Talbotec
- Pediatric Gastroenterology-Hepatology-Nutrition; Necker-Enfants malades Hospital; Paris France
| | - Fabrice Lesage
- Pediatric Intensive Care; Necker-Enfants malades Hospital; Paris France
| | - Virinie Colomb
- Pediatric Gastroenterology-Hepatology-Nutrition; Necker-Enfants malades Hospital; Paris France
| | - Nadège Salvi
- Anesthesiology; Necker-Enfants malades Hospital; Paris France
| | - Florence Moulin
- Pediatric Intensive Care; Necker-Enfants malades Hospital; Paris France
| | | | - Yves Aigrain
- Pediatric Surgery; Necker-Enfants malades Hospital; Paris France
| | - Yann Revillon
- Pediatric Surgery; Necker-Enfants malades Hospital; Paris France
| | - Olivier Goulet
- Pediatric Gastroenterology-Hepatology-Nutrition; Necker-Enfants malades Hospital; Paris France
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