Challenges with intestine and multivisceral re-transplantation

Importance of timing of re-transplantation and optimal immunosuppression

Chandrashekhar A. Kubal, Katherine Pennington, Jonathan Fridell, Burcin Ekser, Plamen Muhaylov, Richard Mangus

Research output: Contribution to journalArticle

Abstract

Background: Patients undergoing re-transplantation often receive high doses of immunosuppression, which may lead to an immunocompromised status of the recipient. This study investigates the outcomes after intestine/multivisceral re-transplantation. Material/Methods: Clinical outcomes of 23 patients undergoing 24 re-transplantations at a single intestine transplant center were reviewed. Bone marrow suppression was used as a surrogate marker of immunocompromised status, and was defined as platelet count <50 k/mm3 and absolute lymphocyte count <200/mm3. Results: All re-transplants except one were liver inclusive. Fifteen of 23 patients died at a median time of 12 months (range 0.2–75) after re-transplantation. Of the 15 deaths, nine (60%) resulted from complications associated with a compromised host immune status: graft versus host disease (GVHD) affecting bone marrow (three cas-es), persistent viral infection (three cases), post-transplant lymphoproliferative disorder (PTLD (one case), met-astatic cancer (one case), multi-drug resistant polymicrobial sepsis (one case). Four deaths (27%) resulted from severe rejection. Non-survivors were more likely to have received alemtuzumab, and had higher incidence of bone marrow suppression. In addition to immunocompromised status and rejection, the use of alemtuzumab was associated with mortality after intestinal/multivisceral re-transplantation. Conclusions: High mortality was associated with intestine/multivisceral re-transplantation. To improve clinical outcomes of intestine and multivisceral transplantation, it is important to allow reconstitution of host immunity. Longer interval between the two transplantations, and strategies such as allograft specific immunosuppression, may spare the host from the devastating effects of potent immunosuppression currently used.

Original languageEnglish (US)
Pages (from-to)98-104
Number of pages7
JournalAnnals of Transplantation
Volume23
DOIs
StatePublished - Jan 1 2018

Fingerprint

Immunosuppression
Intestines
Transplantation
Bone Marrow
Transplants
Lymphoproliferative Disorders
Mortality
Lymphocyte Count
Graft vs Host Disease
Virus Diseases
Platelet Count
Allografts
Immunity
Sepsis
Biomarkers
Outcome Assessment (Health Care)
Liver
Incidence
Pharmaceutical Preparations
Neoplasms

Keywords

  • Graft rejection
  • Graft vs. host disease
  • Immunocompromised host
  • Intestine, small
  • Transplantation

ASJC Scopus subject areas

  • Transplantation

Cite this

Challenges with intestine and multivisceral re-transplantation : Importance of timing of re-transplantation and optimal immunosuppression. / Kubal, Chandrashekhar A.; Pennington, Katherine; Fridell, Jonathan; Ekser, Burcin; Muhaylov, Plamen; Mangus, Richard.

In: Annals of Transplantation, Vol. 23, 01.01.2018, p. 98-104.

Research output: Contribution to journalArticle

Kubal, Chandrashekhar A. ; Pennington, Katherine ; Fridell, Jonathan ; Ekser, Burcin ; Muhaylov, Plamen ; Mangus, Richard. / Challenges with intestine and multivisceral re-transplantation : Importance of timing of re-transplantation and optimal immunosuppression. In: Annals of Transplantation. 2018 ; Vol. 23. pp. 98-104.
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abstract = "Background: Patients undergoing re-transplantation often receive high doses of immunosuppression, which may lead to an immunocompromised status of the recipient. This study investigates the outcomes after intestine/multivisceral re-transplantation. Material/Methods: Clinical outcomes of 23 patients undergoing 24 re-transplantations at a single intestine transplant center were reviewed. Bone marrow suppression was used as a surrogate marker of immunocompromised status, and was defined as platelet count <50 k/mm3 and absolute lymphocyte count <200/mm3. Results: All re-transplants except one were liver inclusive. Fifteen of 23 patients died at a median time of 12 months (range 0.2–75) after re-transplantation. Of the 15 deaths, nine (60{\%}) resulted from complications associated with a compromised host immune status: graft versus host disease (GVHD) affecting bone marrow (three cas-es), persistent viral infection (three cases), post-transplant lymphoproliferative disorder (PTLD (one case), met-astatic cancer (one case), multi-drug resistant polymicrobial sepsis (one case). Four deaths (27{\%}) resulted from severe rejection. Non-survivors were more likely to have received alemtuzumab, and had higher incidence of bone marrow suppression. In addition to immunocompromised status and rejection, the use of alemtuzumab was associated with mortality after intestinal/multivisceral re-transplantation. Conclusions: High mortality was associated with intestine/multivisceral re-transplantation. To improve clinical outcomes of intestine and multivisceral transplantation, it is important to allow reconstitution of host immunity. Longer interval between the two transplantations, and strategies such as allograft specific immunosuppression, may spare the host from the devastating effects of potent immunosuppression currently used.",
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AU - Kubal, Chandrashekhar A.

AU - Pennington, Katherine

AU - Fridell, Jonathan

AU - Ekser, Burcin

AU - Muhaylov, Plamen

AU - Mangus, Richard

PY - 2018/1/1

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AB - Background: Patients undergoing re-transplantation often receive high doses of immunosuppression, which may lead to an immunocompromised status of the recipient. This study investigates the outcomes after intestine/multivisceral re-transplantation. Material/Methods: Clinical outcomes of 23 patients undergoing 24 re-transplantations at a single intestine transplant center were reviewed. Bone marrow suppression was used as a surrogate marker of immunocompromised status, and was defined as platelet count <50 k/mm3 and absolute lymphocyte count <200/mm3. Results: All re-transplants except one were liver inclusive. Fifteen of 23 patients died at a median time of 12 months (range 0.2–75) after re-transplantation. Of the 15 deaths, nine (60%) resulted from complications associated with a compromised host immune status: graft versus host disease (GVHD) affecting bone marrow (three cas-es), persistent viral infection (three cases), post-transplant lymphoproliferative disorder (PTLD (one case), met-astatic cancer (one case), multi-drug resistant polymicrobial sepsis (one case). Four deaths (27%) resulted from severe rejection. Non-survivors were more likely to have received alemtuzumab, and had higher incidence of bone marrow suppression. In addition to immunocompromised status and rejection, the use of alemtuzumab was associated with mortality after intestinal/multivisceral re-transplantation. Conclusions: High mortality was associated with intestine/multivisceral re-transplantation. To improve clinical outcomes of intestine and multivisceral transplantation, it is important to allow reconstitution of host immunity. Longer interval between the two transplantations, and strategies such as allograft specific immunosuppression, may spare the host from the devastating effects of potent immunosuppression currently used.

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KW - Graft vs. host disease

KW - Immunocompromised host

KW - Intestine, small

KW - Transplantation

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