Retrospective Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Transplant. Dec 24, 2016; 6(4): 719-728
Published online Dec 24, 2016. doi: 10.5500/wjt.v6.i4.719
Acute antibody-mediated rejection after intestinal transplantation
Guo-Sheng Wu, Ruy J Cruz Jr, Jun-Chao Cai
Guo-Sheng Wu, Division of Gastrointestinal Surgery, Xijing Hospital of Digestive Diseases, the Fourth Military Medical University, Xi’an 710032, Shaanxi Province, China
Guo-Sheng Wu, Ruy J Cruz Jr, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, United States
Jun-Chao Cai, Terasaki Foundation Laboratory, Los Angeles, CA 90064, United States
Author contributions: Wu GS cared for the patients and collected and summarized the data and wrote the article; Cruz Jr RJ cared for the patients; Cai JC helped for the interpretation of antibody data revising the manuscript.
Institutional review board statement: The University of Pittsburgh Medical Center Institutional Review Board approved this study.
Informed consent statement: Patients were not required to give informed consent because of observational, retrospective nature of the study.
Conflict-of-interest statement: The author declares no conflict of interests for this article.
Data sharing statement: No additional data available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Guo-Sheng Wu, MD, PhD, Division of Gastrointestinal Surgery, Xijing Hospital of Digestive Diseases, the Fourth Military Medical University, #127 Changle West Rd, Xi’an 710032, Shaanxi Province, China. guosheng_w@yahoo.com
Telephone: +86-29-84771508 Fax: +86-29-82539041
Received: August 20, 2016
Peer-review started: August 23, 2016
First decision: September 28, 2016
Revised: November 1, 2016
Accepted: November 21, 2016
Article in press: November 23, 2016
Published online: December 24, 2016
Abstract
AIM

To investigate the incidence, risk factors and clinical outcomes of acute antibody-mediated rejection (ABMR) after intestinal transplantation (ITx).

METHODS

A retrospective single-center analysis was performed to identify cases of acute ABMR after ITx, based on the presence of donor-specific antibody (DSA), acute tissue damage, C4d deposition, and allograft dysfunction.

RESULTS

Acute ABMR was identified in 18 (10.3%) out of 175 intestinal allografts with an average occurrence of 10 d (range, 4-162) after ITx. All acute ABMR cases were presensitized to donor human leukocyte antigens class I and/or II antigens with a detectable DSA. A positive cross-match was seen in 14 (77.8%) cases and twelve of 18 patients (66.7%) produced newly-formed DSA following ITx. Histological characteristics of acute ABMR include endothelial C4d deposits, interstitial hemorrhage, and severe congestion with focal fibrin thrombin in the lamina propria capillaries. Multivariate analysis identified a liver-free graft and high level of panel reactive antibody as a significant independent risk factor. Despite initial improvement after therapy, eleven recipients (61.1%) lost transplant secondary to rejection. Of those, 9 (50%) underwent graft removal and 4 (22.2%) received second transplantation following acute ABMR. At an average follow-up of 32.3 mo (range, 13.3-76.4), 8 (44.4%) recipients died.

CONCLUSION

Our results indicate that acute ABMR is an important cause of intestine graft dysfunction, particularly in a liver-exclusive graft and survivors are at an increased risk of developing refractory acute rejection and chronic rejection. More effective strategies to prevent and manage acute ABMR are needed to improve outcomes.

Keywords: Intestinal transplantation, C4d deposition, Donor-specific antibody, Acute antibody-mediated rejection

Core tip: Antibody-mediated rejection (ABMR) has appeared to be an important cause of allograft failure after intestinal transplantation (ITx). This study aimed to evaluate the incidence, risk factors and clinical outcomes of acute ABMR after ITx. The incidence of acute ABMR after ITx was as high as 10.3% in our series, which was closely associated with poor graft and patient survival. Our results indicate that acute ABMR is an important cause of intestinal graft failure, especially in a liver-free allograft and survivors are at an increased risk of developing chronic rejection. Effective strategies to prevent and treat acute ABMR are needed to improve outcomes.