*Purpose: Review the management of immunosuppression (IS) for intestinal transplantation (IT) in the USA

*Methods: A survey was created and sent via email to surgical directors of centers performing at least 10 IT total over the last 3 years. We asked about human leukocyte antigen (HLA) testing, desensitization, IS and antibody-mediated rejection (AMR)

*Results: 8/10 centers responded. All perform routine HLA donor specific antibody (DSA) testing pre-IT. 37.5% check DSA titers only after infections or transfusions. 62.5% centers transplant through a positive type I DSA crossmatch (some, regardless of MFI titers) while only 37.5% do so with type II DSA crossmatch. In patients with pre-IT DSA, all centers perform follow up testing post-IT, usually every 1-2 weeks. 87.5% do this for those without pre-IT DSA. 50% centers perform pre-IT desensitization for isolated IT and 25% for multivisceral transplants with combinations of intravenous immunoglobulin (IVIg), rituximab, bortezomib or plasmapheresis. 87.5% centers use induction with antithymocyte globulin (ATG). Post-IT, the standard maintenance IS regimen is tacrolimus (FK) and steroids with 25% also using mycophenolate mofetil and 37.5% using an mTor inhibitor. Goal FK level is 10-15 ng/mL in the first 3 months and <10ng/mL beyond 1 year. If a desired level is not achieved, 50% centers use a sublingual (SL) formulation; 12.5% use neither a SL nor intravenous formulation. 75% centers run IS lower with a liver-containing graft. 75% centers perform protocol intestinal biopsies in the absence of symptoms, mostly weekly for the first 3 months post-IT. All centers diagnose AMR with one or more of the following criteria: refractory rejection, increase in DSA titers, C4d staining in tissue or histologic findings. Therapy is performed with plasmapheresis, IVIg, rituximab or steroids. Only 1 center uses bortezomib and none use ATG. When treating moderate/severe acute cellular rejection, the most commonly used agent is ATG (87.5%).

*Conclusions: All centers perform routine HLA DSA testing before IT; the majority check titers pre-IT every 3-6 months. Most centers transplant through a positive type I but not type II DSA crossmatch. Desensitization is mostly performed in isolated IT and when the panel-reactive antibody (PRA) is >70%. While most centers have similar practices for pre-IT DSA testing, transplanting through a positive crossmatch, induction and post-IT IS, there are several different strategies for desensitization and for the diagnosis/therapy of AMR. Formal protocols for desensitization and diagnosis/management of presumed AMR should thus be pursued across centers.

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