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Induction and Maintenance Immunosuppression in Intestinal Transplantation

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Solid Organ Transplantation in Infants and Children

Part of the book series: Organ and Tissue Transplantation ((OTT))

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Abstract

Intestinal and multivisceral transplantation are highly complex and challenging procedures for patients with irreversible and complicated intestinal failure. In recent years, significant improvements in patient and graft survival have been achieved. To date, these results correspond to similar survival rates for patients without life-threatening complications on parenteral nutrition. Graft immunogenicity is a major hurdle and graft rejection remains a potentially life threatening complication after ITX.

Due to significantly improved survival rates, the use of induction therapy for patients undergoing ITX has become standard practice. Lymphocyte depleting agents and interleukin 2 receptor antagonists are commonly used in this setting. The introduction of tacrolimus to clinical practice almost 30 years ago revolutionized the field of ITX and contributed significantly to clinical establishment of this procedure. Combination with antiproliferative agents may turn out to stabilize long-term transplant survival.

Traditional treatment for acute rejection comprises bolus steroids and lymphocyte depletion. Clinical experience has been gained with the use of TNFα-inhibitors in certain states of allograft rejection and inflammation, respectively. However, antibody-mediated mechanisms in intestine rejection have achieved increasing attention.

Experimental research and clinical trials are required to elucidate underlying biologic mechanisms and optimize and identify indications for use for novel immunosuppressive strategies targeting cytokines, B-cells, plasma cells, and complement.

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Abbreviations

ACR:

Acute cellular rejection

AMR:

Antibody-mediated rejection

APC:

Antigen presenting cells

CMV:

Cytomegalovirus

CNI:

Calcineurin-inhibitors

CsA:

Cyclosporine A

DSA:

Donor-specific antibodies

EBV:

Epstein barr virus

GvHD:

Graft versus host disease

HLA:

Human leukocyte antigen

IBD:

Inflammatory bowel disease

IITR:

International intestinal transplant

IL-2R:

IL-2/IL-2 receptor

IR:

Ischemia reperfusion

ITX:

Intestinal transplantation

IVIGs:

Intravenous immunoglobulins

mAb:

Monoclonal antibody

MMF:

Mycophenolate mofetil

mTOR:

Mammalian target of rapamycin

MVTX:

Multivisceral transplantation

NOD:

Nucleotide oligomerization domain

OPTN:

Organ Procurement and Transplantation Network

PTLD:

Posttransplant lymphoproliferative disease

SRTR:

Scientific Registry of Transplant Recipients

TLR:

Toll-like receptors

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Competing Interests

The authors declare that they have no competing interests.

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Authors and Affiliations

  1. Department of Surgery, Charité – Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany

    Georgi Atanasov & Andreas Pascher

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  1. Georgi Atanasov
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  2. Andreas Pascher
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Correspondence to Andreas Pascher .

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Editors and Affiliations

  1. Jefferson Medical College, AI Dupont Hospital for Children Department of Surgery, Wilmington, Delaware, USA

    Stephen P. Dunn

  2. Liver & Intestine Transplantation, Seattle Children’s Hospital Liver & Intestine Transplantation, Seattle, Washington, USA

    Simon Horslen

Section Editor information

  1. Hillman Center for Pediatric Transplantation, Children’s Hospital of Pittsburgh of UPMC, 4401 Penn Avenue (FP, Room 6137), 15224, Pittsburgh, PA, USA

    George Mazariegos

  2. Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA

    Dale Zecca

  3. Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA

    Jennifer Melvin

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Atanasov, G., Pascher, A. (2017). Induction and Maintenance Immunosuppression in Intestinal Transplantation. In: Dunn, S., Horslen, S. (eds) Solid Organ Transplantation in Infants and Children. Organ and Tissue Transplantation. Springer, Cham. https://doi.org/10.1007/978-3-319-08049-9_25-1

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