Induction immunosuppression with thymoglobulin and rituximab in intestinal and multivisceral transplantation.
BACKGROUND
Induction immunosuppression is now a common practice after intestinal and multivisceral transplantation. We report our experience in 27 adult recipients who received rituximab and rabbit antithymocyte globulin (rATG) in combination as induction agents.


METHODS
Twenty-seven adult patients received 29 intestinal transplants between July 2004 and March 2007. All patients received induction immunosuppression therapy with rATG, rituximab, and steroids. Tacrolimums and a steroid taper were used for maintenance therapy. Patient and graft survival, episodes of rejection as well as posttransplant lymphoproliferative disease (PTLD) and graft-versus-host disease were analyzed.


RESULTS
One-year patient and graft survival was 81% and 76%, respectively. Thirteen patients (48%) experienced 19 episodes of acute rejection (9 mild episodes, 2 moderate, and 8 severe). Patients with a multivisceral graft experienced less episodes of severe acute rejection (1 of 19, 5%) when compared with isolated intestinal transplants and modified multivisceral transplants (7 of 10, 70%). Two patients had episodes of skin graft-versus-host disease that responded to steroid boluses. PTLD was not seen in our series. Two patients developed cytomegalovirus enteritis.


CONCLUSIONS
The combination of rATG and rituximab was an effective induction therapy in our preliminary data. The number and severity of rejection episodes increased when the liver was not included as part of the graft. An immunosuppression regimen including rATG, rituximab, and steroids may have a protective effect against PTLD and chronic rejection.
Vianna
Rodrigo M
RM
Department of Surgery, Transplant Section, Indiana University School of Medicine, Indianapolis, Indiana 46202-5260, USA. rvianna@iupui.edu
Mangus
Richard S
RS
Fridell
Jonathan A
JA
Weigman
Sheila
S
Kazimi
Marwan
M
Tector
Joseph
J
D000328:Adult; D000368:Aged; D000911:Antibodies, Monoclonal / Q000627:therapeutic use*; D058846:Antibodies, Monoclonal, Murine-Derived; D000961:Antilymphocyte Serum / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D007422:Intestines / Q000637:transplantation*; D008232:Lymphoproliferative Disorders / Q000209:etiology; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D000069283:Rituximab; D016019:Survival Analysis; D017741:Survivors; D014184:Transplantation, Homologous / Q000276:immunology / Q000502:physiology*; D016896:Treatment Outcome; D014781:Viscera / Q000637:transplantation*
D000911:Antibodies, Monoclonal; D058846:Antibodies, Monoclonal, Murine-Derived; D000961:Antilymphocyte Serum; D007166:Immunosuppressive Agents; D000069283:Rituximab