Abstracts

STEROID-FREE PEDIATRIC INTESTINAL TRANSPLANTATION-FOUR-YEAR EXPERIENCE IN 75 CHILDREN

Rakesh Sindhi, Nandita Khera, Anita Nucci, Lori Kowalski, Graciela Perez, Kyle Soltys, Geoff Bond, Kareem Abu-Elmagd, George Mazariegos. University of Pittsburgh Medical Center, Thomas E Starzl Transplantation Institute, Pittsburgh, PA.

Background/Purpose: To review overall experience of 75 children receiving small bowel transplantation alone or with liver (SBTx, LSBTx) from 3/2002 through 3/2006.

Methods: Immunosuppression was steroid-free Tacrolimus after 5 mg/kg rabbit anti-human thymocyte globulin (rATG), with half the dose of rATG given prior to reperfusion. The most recent 27 children received an additional 2.5 mg/kg rATG post-Tx.

Results: Median age was 2.8 years (0.3-22.6), and follow-up was 25 months (1-48). M:F gender distribution was 43:22, and SBTx: LSBTx ratio was 35:40. Current patient and graft survival are 66/75 (88%) and 64/75 (85%), respectively. Actuarial 1-, 2- and 3-year patient and graft survival was 94% and 91%, 87% and 87%, and 84% and 83%, respectively. Four deaths occurred in the 1st year (outflow obstruction/sepsis-1, sepsis-2, refractory rejection/sepsis-1), and five thereafter (aspiration-1, PTLD-1, sepsis-1, refractory rejection-2). Graft enterectomy in two survivors was performed for internal hernia-1, and refractory rejection-1. Biopsy-proven early (90-day) acute cellular rejection (ACR) occurred in 50/75 (67%) at a median interval of 15 days post-Tx (6-86), and included 21/75 (28%) steroid-resistant ACR. Infectious/malignant complications included CMV disease (n=5, 7%), EBV enteritis (n=10, 13%), adenovirus enteritis (n=22, 29%), and EBV-PTLD (n=5, 7%). Median and mean TAC levels at end of follow-up were 8.9 and 8.4 ng/ml respectively (range 1.5-22.4 ng/ml). The incidence of steroid use at the end of follow-up was 22/75 (29%). Anthropometric measurements in a sub-cohort of 33 children demonstrated that 137% of expected linear growth velocity was achieved at 2 years. Within this subcohort, children who remained steroid-free (n=16) also demonstrated mean z-scores for linear growth, that were less negative over time (preTx score -2.25, 1-year score -1.91, and 2-year score -1.61) compared with those children who continued to require steroids (n=17. PreTx, 1-year and 2-year scores of -2.96, -2.88, and -2.59, respectively).

Conclusions: Steroid avoidance and pre-Tx lymphocyte depletion is associated with early and intermediate-term survival in pediatric SBTx, which is similar to that for other organs. This advance is associated with reduced morbidities due to reduced maintenance immunosuppressants, and with favorable growth trends expected from steroid avoidance.