Intestinal transplantation: evolution in immunosuppression protocols

Abstract

Purpose of review: Intestinal transplantation is a treatment for patients with short bowel syndrome and associated severe complications. The intestine has long been seen as a 'forbidden' organ to transplant. This fact is because the first attempts at intestinal transplantation were rapidly defeated by rejection and sepsis.

Recent findings: Several factors have contributed to improve the results: tacrolimus-based immunosuppression, induction therapy (independent of the type), introduction of ganciclovir and rituximab and subsequent better control of cytomegalovirus and posttransplant lymphoma, better differential diagnosis between rejection versus infection and ischemia (avoiding unnecessary overimmunosuppression), better patient follow-up. Center experience is more important than a particular immunosuppressive protocol. M-TOR inhibitors, infliximab have been used. Mycophenolate mofetil is less frequently used because of its potential gastrointestinal toxicity. Of note, no significant improvement in short-term and long-term (>1 year) survival was observed since 2000 and 1985, respectively.

Summary: Intestinal transplantation remains a formidable clinical/immunological challenge. With newer immunosuppression and accumulated experience, intestinal transplantation results have improved and the procedure represents a life-saving option in patients with short bowel syndrome-related complications. Before intestinal transplantation becomes a 'quality of life-improving' procedure (offered to patients who are free of short bowel syndrome-related complications), new strategies focusing on facilitating graft acceptance and reducing the need for immunosuppression will have to be developed.