Introduction

Small bowel transplantation can be performed for short bowel syndrome. The ideal immunosuppressive regimen after small bowel transplantation still needs to be defined. Here we report on our experience with daclizumab and alemtuzumab induction therapy for small bowel transplantation.

Methods

From 2007 until 2012 we have transplanted 10 patients (28-57 years) with short bowel syndrome because of complications related to total parenteral nutrition. Four patients with histology proven fibrosis or cirrhosis of the liver received a combined liver and small bowel graft. The immunosuppressive regimen consisted of tacrolimus, prednisolone, mycophenolate mofetil and daclizumab (n=4) or alemtuzumab (n=6) for induction therapy. Every small bowel was harvested by our own team (donor age 16-46 years). Parallel to the small bowel harvest the recipient was operated in order to minimize cold ischemia time (379 ± 129 minutes).

Results

Two patients with a combined liver and small bowel graft died within three months after the transplantation due to septic complications with multiorgan failure. Both patients received daclizumab for induction therapy, their grafts had the longest time of cold ischemia and the highest donor age in our series. One graft was lost due to chronic rejection. Up to five years after transplant, seven patients present with a functioning small bowel graft. One patient after combined liver and small bowel transplantation was successfully kidney transplanted during follow-up because of renal insufficiency. Protocol biopsies did not detect acute rejection in any of the patients. Apart from one patient with cryptococcosis, who was treated successfully, we did not observe infectious complications with alemtuzumab for induction therapy.

Conclusions

Alemtuzumab induction therapy for small bowel transplantation followed by triple immunosuppression with tacrolimus, prednisolone and mycophenolate mofetil is a safe regimen and appears to be superior to daclizumab induction therapy in our series. Our experience suggests to choose a donor younger than thirty years of age and to aim for less than eight hours of cold ischemic time. The ideal time point for small bowel transplantation appears to be before onset of vascular problems and irreversible liver disease.

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