Analysis of Acute Cellular Rejection Episodes in Recipients of Primary Intestinal Transplantation: A Single Center, 11-Year Experience

Abstract

Intestinal transplantation has evolved over the years with major improvements in patient and graft survival. Acute cellular rejection of the intestine, however, still remains one of the most challenging aspects of postoperative management. We analyzed retrospectively collected data from 209 recipients of primary intestinal grafts at our institution over the past 11 years. A total of 290 episodes of biopsy-proven rejection requiring clinical treatment were analyzed. Rejection episodes doubled in length, on average, with each increasing grade (mild, moderate, severe). We observed increased incidence of overall rejection and particularly severe rejection in recipients of isolated intestinal and liver-intestine grafts in comparison with multivisceral grafts. Two rejection history variables had a significant negative impact on graft survival: the occurrence of a severe rejection episode and a rejection episode lasting ≥21 days. The lower incidence rate of severe rejection in recipients of multivisceral grafts might be due to a combination of increased donor lymphatic tissue and larger load of donor-derived immune competent cells present in the graft. The development of more effective monitoring and treatment protocols to prevent the occurrence of severe and/or lengthy rejection episodes is of critical importance for intestinal graft survival.

MicroRNA Signature of Intestinal Acute Cellular Rejection in Formalin-Fixed Paraffin-Embedded Mucosal Biopsies

“…However, acute cellular rejection (ACR) is the major cause of intestinal graft failure after SBT. In fact, despite aggressive immunosuppressive therapy, most patients with severe ACR experience progression to graft loss (1)(2)(3). Multivisceral transplantation (MVT) is one of the forms of SBT.…”

Rejection Reversibly Alters Enteroendocrine Cell Renewal in the Transplanted Small Intestine

“…Graft failure secondary to rejection occurs in about 30-40% of transplants within the first 3 years postoperatively. The first episode of rejection occurs within the first 3 months following transplantation in over 80% of allograft recipients (1,3). (1) …”

Clinical Allograft Rejection Syndromes in Intestinal Transplantation

“…The initial episode of acute rejection is typically seen around 2-4 weeks. More than 70% of all rejection episodes are observed within the first year of transplant [11]. It is widely documented that the presence of a liver graft within the intestinal transplant confers the intestinal graft some degree of protection from developing ACR as compared to intestinal graft alone [2,4,12,13].…”

“…It is widely documented that the presence of a liver graft within the intestinal transplant confers the intestinal graft some degree of protection from developing ACR as compared to intestinal graft alone [2,4,12,13]. There is evidence that the multivisceral graft may provide some protection even in the absence of a liver [3,11].…”