Clinical intestinal transplantation: A decade of experience at a single center

Objective To assess the long-term efficacy of intestinal transplantation un der tacrolimus-based immunosuppression and the therapeutic benefit of newly developed adjunct immunosuppressants and management strategies. Summary Background Data With the advent of tacrolimus in 1990, transplantat ion of the intestine began to emerge as therapy for intestinal failure. How ever, a high risk of rejection, with the consequent need for acute and chro nic high-dose immunosuppression, has inhibited its widespread application. Methods During an 11-year period, divided into two segments by a 1-year mor atorium in 1994, 155 patients received 165 intestinal allografts under immu nosuppression based on tacrolimus and prednisone: 65 intestine alone, 75 li ver and intestine, and 25 multivisceral. For the transplantations since the moratorium (n = 99), an adjunct immunosuppressant (cyclophosphamide or dac lizumab) was used for 74 transplantations, adjunct donor bone marrow was gi ven in 39, and the intestine of 11 allografts was irradiated with a single dose of 750 cGy. Results The actuarial survival rate for the total population was 75% at 1 y ear, 54% at 5 years, and 42% at 10 years. Recipients of liver plus intestin e had the best long-term prognosis and the lowest risk of graft loss from r ejection (P = .001). Since 1994, survival rates have improved. Techniques f or early detection of Epstein-Barr and cytomegaloviral infections, bone mar row augmentation, the adjunct use of the interleukin-2 antagonist daclizuma b, and most recently allograft irradiation may have contributed to the bett er results. Conclusion The survival rates after intestinal transplantation have cumulat ively improved during the past decade. With the management strategies curre ntly under evaluation, intestinal transplant procedures have the potential to become the standard of care for patients with end-stage intestinal failu re.