https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.1840170629

Cell migration and chimerism after whole-organ transplantation: The basis of graft acceptance

Importance The field of transplantation has made tremendous progress since the first successful kidney transplant in 1954. Objective To determine the survival benefit of solid-organ transplant as recorded during a 25-year study period in the United Network for Organ Sharing (UNOS) database and the Social Security Administration Death Master File. Design, Setting, and Participants In this retrospective analysis of UNOS data for solid-organ transplant during a 25-year period (September 1, 1987, through December 31, 2012), we reviewed the records of 1 112 835 patients: 533 329 recipients who underwent a transplant and 579 506 patients who were placed on the waiting list but did not undergo a transplant. Main Outcomes and Measures The primary outcome was patient death while on the waiting list or after transplant. Kaplan-Meier survival functions were used for time-to-event analysis. Results We found that 2 270 859 life-years (2 150 200 life-years from the matched analysis) were saved to date during the 25 years of solid-organ transplant. A mean of 4.3 life-years were saved (observed to date) per solid-organ transplant recipient. Kidney transplant saved 1 372 969 life-years; liver transplant, 465 296 life-years; heart transplant, 269 715 life-years; lung transplant, 64 575 life-years; pancreas-kidney transplant, 79 198 life-years; pancreas transplant, 14 903 life-years; and intestine transplant, 4402 life-years. Conclusions and Relevance Our analysis demonstrated that more than 2 million life-years were saved to date by solid-organ transplants during a 25-year study period. Transplants should be supported and organ donation encouraged.

https://jamanetwork.com/journals/jamasurgery/articlepdf/2100153/soi140092.pdf

Survival Benefit of Solid-Organ Transplant in the United States

It has been only 14 years since the first scattered examples were recorded of extended survival in humans of nutrition-supporting intestinal allografts transplanted under cyclosporine-based immunosuppression. 1–6 Then, with the advent of tacrolimus in 1989 to 1990, 7,8 clinical intestinal transplantation began to emerge as a practical means of treating intestinal failure. 9–15 Multiple factors have sustained and increased these efforts, including technical innovations in surgery and improvements in nonspecific postoperative care.

The most important therapeutic achievement, however, has been the increasingly efficient prevention and/or control of rejection, exemplified by our experience reported here with 155 recipients of 165 intestinal, liver-intestinal, or multivisceral abdominal allografts whose transplantations were performed between May 2, 1990, and February 18, 2001. The emphasis in this analysis will be placed on the long-term outlook of patients who were still alive at the time of previous reports, and on attempts to improve the prognosis with new adjunct immunosuppressants or management strategies that have yielded promising results in laboratory models.

/pdf/clinical-intestinal-transplantation-a-decade-of-experience-xiiwjzxsb6.pdf

Clinical Intestinal Transplantation: A Decade of Experience at a Single Center

Objective The aim of the study was to determine risk factors associated with graft failure and mortality after transplantation of the intestine alone or as part of an organ complex. Background Data Even with modern immunosuppressive therapies, clinical intestinal transplantation remains a difficult and unreliable procedure. Causes for this and solutions are needed. Methods Between May 1990 and February 1995, 71 intestinal transplantations were performed in 66 patients using tacrolimus and low-dose steroids. The first 63 patients, all but one treated 1 to 5 years ago, received either isolated grafts (n = 22), liver and intestinal grafts (n = 30), or multivisceral grafts (n = 11). Three more recipients of allografts who recently underwent surgery and one undergoing retransplantation were given unaltered donor bone marrow cells perioperatively as a biologic adjuvant. Results Of the first 63 recipients, 32 are alive : 28 have functioning primary grafts and 4 have resumed total parenteral nutrition after graft enterectomy. Thirty-five primary grafts were lost to technical and management errors (n = 10), rejection (n = 6), and infection (n = 19). Regression analysis revealed that duration of surgery, positive donor cytomegalovirus (CMV) serology, inclusion of graft colon, OKT3 use, steroid recycle, and high tacrolimus blood levels contributed to graft loss. All four intestine and bone marrow recipients are alive for 2-3 months without evidence of graft-versus-host disease. Conclusion To improve outcome after intestinal transplantation with previous management protocols, it will be necessary to avoid predictably difficult patients, CMV seropositive donors, and inclusion of the graft colon. Bone marrow transplantation may further improve outcome by ameliorating the biologic barriers of rejection and infection and allowing less restrictive selection criteria.

/pdf/outcome-analysis-of-71-clinical-intestinal-transplantations-e3387lt2ca.pdf

Outcome analysis of 71 clinical intestinal transplantations

Under FK 506-based immunosuppression, the entire cadaver small bowel except for a few proximal and distal centimeters was translated to 17 randomly matched patients, of whom two had antigraft cytotoxic antibodies (positive cross-match). Eight patients received the intestine only, eight had intestine in continuity with the liver, and one received a full multivisceral graft that included the liver, stomach, and pancreas. One liver-intestine recipient died after an intestinal anastomotic leak, sepsis, and graft-versus-host disease. The other 16 patients are alive after 1 to 23 months, in one case after chronic rejection, graft removal, and retransplantation. Twelve of the patients have been liberated from total parenteral nutrition, including all whose transplantation was 2 months or longer ago. The grafts have supported good nutrition, and in children, have allowed growth and weight gain. Management of these patients has been difficult and often complicated, but the end result has been satisfactory in most cases, justifying further clinical trials. The convalescence of the eight patients receiving intestine only has been faster and more trouble free than after liver-intestine or multivisceral transplantation, with no greater difficulty in the control of rejection.

/pdf/intestinal-transplantation-in-composite-visceral-grafts-or-gbukb594i3.pdf

Intestinal transplantation in composite visceral grafts or alone.

Successful small bowel transplantation in an infant.

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Successful small bowel transplantation in an infant.