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Induction and Maintenance Immunosuppression in Intestinal Transplantation

  • Georgi Atanasov
  • Andreas Pascher
Reference work entry
Part of the Organ and Tissue Transplantation book series (OTT)

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.

Keywords

Intestinal transplantation Multivisceral transplantation Immunosuppression Biologicals Allograft rejection Allograft enteropathy Induction immunosuppression TNF-alpha-Inhibitors 

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

Notes

Competing Interests

The authors declare that they have no competing interests.

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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of SurgeryCharité – Universitätsmedizin BerlinBerlinGermany

Section editors and affiliations

  • George Mazariegos
    • 1
  • Dale Zecca
    • 2
  • Jennifer Melvin
    • 3
  1. 1.Hillman Center for Pediatric TransplantationChildren’s Hospital of Pittsburgh of UPMCPittsburghUSA
  2. 2.Children’s Hospital of PittsburghPittsburghUSA
  3. 3.Children’s Hospital of PittsburghPittsburghUSA

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