Abdominal Wall Transplantation: Skin as a Sentinel Marker for Rejection

Abstract

These authors contributed equally.Abdominal wall transplantation (AWTX) has revolutionized difficult abdominal closure after intestinal transplantation (ITX). More important, the skin of the transplanted abdominal wall (AW) may serve as an immunological tool for differential diagnosis of bowel dysfunction after transplant. Between August 2008 and October 2014, 29 small bowel transplantations were performed in 28 patients (16 male, 12 female; aged 41 AE 13 years). Two groups were identified: the solid organ transplant (SOT) group (n = 15; 12 ITX and 3 modified multivisceral transplantation [MMVTX]) and the SOT-AWTX group (n = 14; 12 ITX and 2 MMVTX), with the latter including one ITX-AWTX retransplantation. Two doses of alemtuzumab were used for induction (30 mg, 6 and 24 h after reperfusion), and tacrolimus (trough levels 8-12 ng/mL) was used for maintenance immunosuppression. Patient survival was similar in both groups (67% vs. 61%); however, the SOT-AWTX group showed faster posttransplant recovery, better intestinal graft survival (79% vs. 60%), a lower intestinal rejection rate (7% vs. 27%) and a lower rate of misdiagnoses in which viral infection was mistaken and treated as rejection (14% vs. 33%). The skin component of the AW may serve as an immune modulator and sentinel marker for immunological activity in the host. This can be a vital tool for timely prevention of intestinal graft rejection and, more important, avoidance of overimmunosuppression in cases of bowel dysfunction not related to graft rejection.

The difficult abdominal closure after paediatric intestinal transplantation: Use of abdominal rectus muscle fascia and literature review

“…The Oxford group describe their experience with using the abdominal wall transplant skin as a sentinel marker for rejection in 13 adult patients transplanted using the microvascular technique, including five abdominal wall transplants with temporary remote vascularization in the forearm because of a predicted long cold ischaemia time of the AWT . This group had six episodes of rejection and two episodes of graft versus host disease (GVHD).…”

Vascularised Composite Allotransplantation – Basic Science and Clinical Applications

“…The clinical utility of early signs of acute rejection being visible on the skin component of a VCA is the focus of on-going research. The role of the AWT as a sentinel skin graft leading to early detection and treatment of rejection for both VCA and underlying ISB/MVT has been demonstrated [87][88][89]. This may be translated to reduced morbidity by avoiding over immunosuppression.…”

Abdominal wall allotransplantation

“…The authors concluded that simultaneous AWA and VOA offers four advantages. (a) It is possible to perform a comfortable closure of the AW; (b) the skin of the AW may be used as an early marker of intestinal rejection; (c) it can help to clarify GVHD and (d) it can be useful for differential diagnosis between intestinal inflammation and rejection 34,35 .…”

“…The immunosuppressive regimen in AWA is similar to that used in other VCA or organ transplantation procedures. Induction immunosuppression usually starts with alemtuzumab or daclizumab 8,21,24,30,34 . Maintenance immunosuppression is usually a combination of tacrolimus, mycophenolate mofetyl and prednisone.…”

“…Maintenance immunosuppression is usually a combination of tacrolimus, mycophenolate mofetyl and prednisone. Sometimes only tacrolimus with corticosteroids is used 8,21,30 or even monotherapy with tacrolimus 21,24,34 . For rejection periods, boluses of corticosteroids are effective with or without increasing the dose of other immunosupressants.…”