Introduction: Can the skin component of a synchronously transplanted vascularised composite allograft (VCA) be used as a pre-rejection marker for the intestinal transplant (IT)?

Methods: Recipients of a combined IT and VCA were studied and compared to those an earlier cohort who only received an IT.

Results: From October 2008 to November 2014, 32 patients had an IT. Fifteen patients had an IT without the VCA and 17 had an IT with a VCA. In the latter group, 15 had abdominal wall transplants (AWT) and 2 sentinel skin flaps (SSF). Induction immunosuppression was similar in both groups with Campath-1H (Genzyme, USA), 30 mg intravenously, 6 hours after reperfusion and 24 hours later. Maintenance was with Tacrolimus at a trough level of 8-12 ng/ml. At a mean follow-up of 40 months (range 5-65), 22 patients are alive and well. All VCA's were successful. There were 5 intestinal rejections in the IT alone group and 1 intestinal rejection in the IT + VCA group (lead time of 10 days between VCA and IT). There were 5 rejections in the VCA part of the IT+ VCA group. A further 5 patients in the IT group were falsely treated for biopsy proven rejection. This was later labelled as infection. False positive diagnosis of rejection was not observed in the IT+VCA group. Rejection of the intestine in the IT alone group resulted in a mean hospital stay of 45 days (range 15-63). Rejection of the VCA in the IT+VCA group resulted in a mean hospital stay of 4 days (range 3-5).

Discussion: VCA to complement IT provides a visual, dynamic canvas for remote immune monitoring of visceral grafts. The skin component of the VCA may act as an immunologic 'ghost target' that may help divert the cellular affect away from the IT. Conversely, intestinal graft dysfunction with a clear VCA is a dynamic visual canvas for the clinician. This helps to refute the diagnosis of rejection.

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