Treatment for and outcome after intestine acute cellular rejection: results from a multi-center collaborative in the United States

Document Type

Conference Proceeding

Publication Date

1-1-2026

Publication Title

Am J Transplant

Abstract

Background: Intestinal transplantation (ITx) can be a curative treatment for intestinal failure resulting in complications of total parenteral nutrition. In this study, we sought to describe the pathologic diagnosis and treatment regimens used for intestinal ACR in the United States. Secondly, we sought to describe the cumulative experience with treatment response for intestine ACR including sequelae of ACR and treatment. Methods: A survey of 13 US transplant centers[1] involved in ITx was used to determine the diagnostic criteria, first and second-line treatment approach for ACR (including post-ACR surveillance, infection prophylaxis, and management of positive donor specific antibodies DSA). We additionally surveyed respondents on their experience with treating ACR over a three-year period (2021-2023) including treatment outcomes.Results: Definition of ACR used by most centers was similar and related to diagnostic criteria including apoptotic figures, crypt loss/dropout, erosions/ulcerations. Most centers used criteria defined by Wu et al. [2]. Variability in first- and second-line treatment strategies for ACR was observed. Most respondents reported using steroids at variable doses for mild ACR and immunosuppression optimization along with infectious prophylaxis. The centers surveyed reported performing a cumulative of 206 ITx procedures during the study period (68% of which were for pediatric patients, and 67% of which were liver-containing grafts). During the same time, respondents reported treating a total of 116 ACR episodes, of which 33 were DSA-positive at the time of diagnosis (28%). 53% of ACR was responsive to first-line therapy, and an additional 34% responded after second-line therapy. Graft-loss was observed in 19% of ACR events (which was more common in liver-free ITx recipients than in liver-containing recipients (24% vs. 10%). Patient mortality resultant from ACR was 14%. Infectious complications were reported in 40% of patients treated for ACR. Adverse effects such as drug-toxicity, PTLD, GVHD, and TMA were less frequent after treatment for ACR (<10% each). Recurrence of ACR 1-year after first episode happened frequently (31%). Discussion: ACR remains a common complication following ITx with high rate of sequelae including graft-loss, mortality, and infectious complications. Conversely PTLD, GVHD and TMA are infrequent complications. We provide a contemporary description of the definition, treatment choice, and clinical response to first- and second-line treatment for ACR in ITx in the United States.

Volume

26

Issue

1

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