Intestinal transplantation before and after the introduction of sirolimus.
BACKGROUND
Small bowel transplantation has been limited by high rates of rejection and graft loss. In June 2000, we began using sirolimus, an immunosuppression agent with proven efficacy in kidney transplantation. We reviewed results among intestinal transplant recipients before and after the introduction of sirolimus.


METHODS
Thirty-one intestinal transplants were performed in 29 patients at our center between July 1998 and April 2001. All patients were followed for at least 30 days posttransplant. In the first 19 transplants (group 1), patients received tacrolimus, steroids, and antibody induction therapy (either daclizumab or OKT3). In the next 12 consecutive transplants (group 2), patients received tacrolimus, steroids, basiliximab, and sirolimus.


RESULTS
Eighteen children (7 males and 11 females, mean age 2.1+/-2.2 years) and 11 adults (9 males and 2 females, mean age 38.1+/-12.4 years) underwent transplantation. All patients survived transplantation. The overall reoperation rate was 1.7 procedures per patient in group 1 and 1.1 procedures per patient in group 2. The most common indications were abscess (n=7), planned second look (n=7), leaks/fistulas (n=6), dehiscence (n=6), obstruction (n=4), ischemic bowel (n=3), perforations (n=3), stomal complications (n=3), and graft removal (n=3). The incidence of biopsy-proven rejection in the first 30 days was 73.7% in group 1 and 16.7% in group 2 (P<0.002). Sirolimus was temporarily held or discontinued in 66.7% of patients. Actuarial 1-year graft survival was 91.7% with sirolimus and 57.9% without sirolimus (P<0.04). Actuarial 1-year patient survival was 91.7% with sirolimus and 79% without sirolimus (P=0.12).


CONCLUSIONS
An immunosuppressive regimen that includes sirolimus has improved graft survival. Furthermore, this regimen has significantly decreased the incidence of early rejection and has eliminated early graft loss caused by fulminant rejection.
Fishbein
Thomas M
TM
Recanati/Miller Transplantation Institute, Mount Sinai School of Medicine, New York, NY, USA. thomas.fishbein@mountsinai.org
Florman
Sander
S
Gondolesi
Gabriel
G
Schiano
Thomas
T
LeLeiko
Neal
N
Tschernia
Allan
A
Kaufman
Stuart
S
D000328:Adult; D018572:Disease-Free Survival; D005260:Female; D006084:Graft Rejection / Q000453:epidemiology / Q000517:prevention & control; D006085:Graft Survival / Q000502:physiology*; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D007422:Intestines / Q000637:transplantation*; D008297:Male; D012189:Retrospective Studies; D020123:Sirolimus / Q000627:therapeutic use*; D016019:Survival Analysis; D013997:Time Factors; D014184:Transplantation, Homologous / Q000276:immunology / Q000401:mortality / Q000502:physiology*
D007166:Immunosuppressive Agents; D020123:Sirolimus