*Purpose: Review the frequency, indications and outcomes of the use of mTOR inhibitors (mTOR) after intestine (IT) and multivisceral transplantation (MVT) at multiple centers in the United States (USA)

*Methods: We compiled retrospective data from patients receiving sirolimus or everolimus following isolated IT or MVT between 2009-2018 at multiple transplant centers in the USA

*Results: A total of 22 patients received an mTOR. Twenty were over 18 years old, two were children. Mean age at the time of transplant was 46 years in adults (range 22 to 62 years) and 2.5 in children. 12 patients received isolated IT. The most common reason for transplant was short gut syndrome (45%) followed by dysmotility (22%) and neuroendocrine tumor (18%). The mean time from transplant to initiation of mTOR was 24 months (range 1 to 78 months). 54% patients were started beyond 1 year post transplant. 63.6% received sirolimus and 36.4% received everolimus. Reason for mTOR use was renal dysfunction in 59% cases. Mean glomerular filtration rate (GFR) prior to mTOR initiation was 40mL/min/1.73sqm. Of those placed on mTOR for renal insufficiency (13/22), 69.2% had substantial improvement in GFR (defined as an increase of 10 points). Only one patient had kidney disease pre transplant. Other agents at initiation included tacrolimus, prednisone, mycophenolate mofetil (MMF) or azathioprine. 18%, 13.6% and 59% of patients on mTOR were able to discontinue MMF, prednisone or reduce tacrolimus respectively. Only one patient was weaned to mTOR as single immunosuppression agent. mTOR was discontinued in 50% of cases due to side effects (54.5%), surgeries (18.1%) or acute cellular rejection (ACR) (9%). Sirolimus was discontinued in 8/14 (57%), everolimus was discontinued in 3/8 (37.5%). The mean duration of mTOR use in those stopping therapy due to side effects was 7 months and 18 months in those remaining on therapy. 9 patients developed some worsening of proteinuria but none were taken off treatment due to this. 27.3% cases developed ACR, 13.6% had cytomegalovirus and two patients died while being on mTOR therapy.

*Conclusions: mTOR use was safe and efficacious following intestine and multivisceral transplantation in this retrospective multicenter study. Tolerance of therapy remains challenging with 27.2% patients unable to tolerate long term treatment due to side effects.

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