A National Survey of Immunosuppression Strategies in Intestinal Transplantation
Segovia M, Beduschi T, Boike J, Farmer D, Horslen S, Iyer K, Jafri S, Langnas A, Matsumoto C, Mavis A, Mazariegos G, Nagai S, O'Leary J, Patel Y, Sudan D, Sulejmani N, Summers B, and Schiano T. A National Survey of Immunosuppression Strategies in Intestinal Transplantation. Am J Transplant 2019; 19:540.
Am J Transplant
Purpose: Review the management of immunosuppression (IS) for intestinal transplantation (IT) in the USA Methods: A survey was created and sent via email to surgical directors of centers performing at least 10 IT total over the last 3 years. We asked about human leukocyte antigen (HLA) testing, desensitization, IS and antibody-mediated rejection (AMR) Results: 8/10 centers responded. All perform routine HLA donor specific antibody (DSA) testing pre-IT. 37.5% check DSA titers only after infections or transfusions. 62.5% centers transplant through a positive type I DSA crossmatch (some, regardless of MFI titers) while only 37.5% do so with type II DSA crossmatch. In patients with pre-IT DSA, all centers perform follow up testing post-IT, usually every 1-2 weeks. 87.5% do this for those without pre-IT DSA. 50% centers perform pre-IT desensitization for isolated IT and 25% for multivisceral transplants with combinations of intravenous immunoglobulin (IVIg), rituximab, bortezomib or plasmapheresis. 87.5% centers use induction with antithymocyte globulin (ATG). Post-IT, the standard maintenance IS regimen is tacrolimus (FK) and steroids with 25% also using mycophenolate mofetil and 37.5% using an mTOR inhibitor. Goal FK level is 10-15 ng/mL in the first 3 months and <10ng/mL beyond 1 year. If a desired level is not achieved, 50% centers use a sublingual (SL) formulation; 12.5% use neither a SL nor intravenous formulation. 75% centers run IS lower with a liver-containing graft. 75% centers perform protocol intestinal biopsies in the absence of symptoms, mostly weekly for the first 3 months post-IT. All centers diagnose AMR with one or more of the following criteria: refractory rejection, increase in DSA titers, C4D staining in tissue or histologic findings. Therapy is performed with plasmapheresis, IVIg, rituximab or steroids. Only 1 center uses bortezomib and none use ATG. When treating moderate/severe acute cellular rejection, the most commonly used agent is ATG (87.5%). Conclusions: All centers perform routine HLA DSA testing before IT; the majority check titers pre-IT every 3-6 months. Most centers transplant through a positive type I but not type II DSA crossmatch. Desensitization is mostly performed in isolated IT and when the panel-reactive antibody (PRA) is >70%. While most centers have similar practices for pre-IT DSA testing, transplanting through a positive crossmatch, induction and post-IT IS, there are several different strategies for desensitization and for the diagnosis/therapy of AMR. Formal protocols for desensitization and diagnosis/management of presumed AMR should thus be pursued across centers.