2017 - CIRTA

Introduction:  Acute cellular rejection (ACR) after intestinal transplantation (ITX), can lead to graft loss and mortality. Absent a clinical or biochemical marker, regular "endoscopy and biopsy" (ENDOBX) has been considered the gold standard for allograft surveillance. We report a single center experience comparing routine surveillance ENDOBX to a protocol of ENDOBX only ‘for cause’. Under the revised protocol, indications for ENDOBX were: 1. significant changes in amount or characteristics of stoma output, 2. fever of unknown origin, or 3. SIRS, without clear source. Primary end points were patient and graft survival.  Secondary end points included incidence and severity of ACR and rates of graft salvage after ACR.

Method: Prospectively maintained data base was reviewed from 2011 to 2016. Our original protocol for surveillance ENDOBX was once a week for the first 6 weeks after ITX. Starting July 2014, ENDOBXwas performed only ’for cause’. Patients were divided into 2 groups; Group 1: Routine protocol ENDOBX and Group 2: ”For cause’ ENDOBX.  Immunosuppressive therapy has been consistent throughout the study period using anti-thymocyte globulin (ATG) induction (6 mg/kg divided into 3 doses) with Tacrolimus and steroid maintenance therapy. Target Tacrolimus level was 15 ng/ml for first 3 months and slowly decreased to 8 -10 ng/ml by one year after ITX. ACR was treated with steroid bolus. Steroid resistant ACR or severe ACR was treated with ATG to a maximum dose of 10 mg/kg.

Result: There were 63 ITX (isolated ITX 44, ITX with kidney 7, ITX with pancreas 4, multivisceral 8) in 58 patients during the study period. For this report, we excluded 8 multi-visceral transplants that included liver and 2 ITX with early graft loss (<2 days). 53 intestinal grafts in 49 patients were analyzed. Routine protocol ENDOBX group included 28 grafts in 27 patients. ‘For cause’ ENDOBX group included 25 grafts in 23 patients (Table 1).

Conclusion: Routine protocol surveillance ENDOBX does not seem to confer any survival advantage after ITX, for patients or grafts.  Increased frequency of surveillance ENDOBX did not correlate with greater graft salvage rate after ACR. ENDOBX for specific clinical concerns seems to be as effective as routine protocol ENDOBX to monitor intestinal grafts with comparable clinical outcome. Such a selective protocol requires careful monitoring by experienced transplant physicians. Our data does not permit us to comment on longer term outcomes.