title: Intestinal and multivisceral transplantation immunosuppression protocols--literature review.
abstract: BACKGROUND
  Currently the most used techniques for small bowel transplant are isolated intestinal transplantation, multivisceral transplantation (MVT), and modified multivisceral transplantation. One important factor is early diagnosis of acute cellular rejection (ACR). In addition, improvements in immunosuppression have recently reduced the number and enhanced treatment of ACR episodes, enabling graft recovery.
  
  
  OBJECTIVE
  We analyzed immunosuppression protocols of leading transplantation centers in the last 5 years.
  
  
  METHODS
  We reviewed papers published in PubMed from major multivisceral and intestinal transplantation centers from 2006 to 2010 in adult recipients. The 211 adults transplanted in seven centers were divided into three groups according to the immunosuppression protocol used: protocol 1: daclizumab induction with tacrolimus and steroid maintenance; protocol 2: alemtuzumab and tacrolimus; and protocol 3: thymoglobulin and rituximab and tacrolimus.
  
  
  RESULTS
  Protocol 2 showed the lowest rate of ACR (34%). Protocols 1 and 3 displayed 54% and 48% ACR rates; respectively. However, protocol 1 patients developed only mild ACR, whereas those in protocols 2 and 3 developed moderate ACR in 26.3% and 11.7%, and severe ACR in 7.9% and 47% of cases, respectively. The infection rate was considerably lower in protocol 3 (7.4%). Protocols 1 and 2 showed infection rates of 62.5% and 52%, respectively. One-year patient survival rates were 70%, 79% and 81%, respectively. Three-year patient survival rates were 62%, 56%, and 78% for protocols 1, 2 and 3, respectively.
  
  
  CONCLUSIONS
  Protocol 2 was the strongest immunosuppressive regimen capable of reducing ACR rates when compared with the other protocols, but the strong effect resulted in high infection rate that impacts 1-year patient survival. Protocol 3 seems to be the best available one balancing ACR and infection rates.
authors.affiliation: Faculdade de Ciências Médicas da Santa Casa de São Paulo, Brazil.
authors.forename: A P
authors.initials: AP
authors.lastname: Trevizol
authors.forename: A I
authors.initials: AI
authors.lastname: David
authors.forename: E R
authors.initials: ER
authors.lastname: Dias
authors.forename: D
authors.initials: D
authors.lastname: Mantovani
authors.forename: R
authors.initials: R
authors.lastname: Pécora
authors.forename: L A C
authors.initials: LA
authors.lastname: D'Albuquerque
mesh_terms: D000328:Adult; D003141:Communicable Diseases / Q000276:immunology; D004359:Drug Therapy, Combination; D006084:Graft Rejection / Q000276:immunology / Q000401:mortality / Q000517:prevention & control*; D006085:Graft Survival / Q000187:drug effects*; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000627:therapeutic use*; D007422:Intestines / Q000637:transplantation; D016377:Organ Transplantation / Q000009:adverse effects / Q000401:mortality; D016019:Survival Analysis; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome; D014781:Viscera / Q000637:transplantation*
chemical_list: D007166:Immunosuppressive Agents