Unique technical and patient characteristics of retransplantation: A detailed single-center analysis of intestinal transplantation.

Robert S. Venick^1,2, Laura J. Wozniak², Khiet Ngo⁴, Jorge Vargas², Elizabeth A. Marcus², Susan Ponthieux¹, Villy Hwang¹, Vatche G. Agopian¹, Ali Zarrinpar¹, Sue V. McDiarmid^1,2, Ronald W. Busuttil¹, Douglas G. Farmer¹

¹Surgery/Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; ²Pediatric Gastroenterology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; ⁴Pediatric Gastroenterology, Loma Linda University Medical Center, Loma Linda, CA, United States

Introduction: Intestinal retransplantation (Re-ITx) is a challenging endeavor traditionally resulting in poor outcomes. There are very few published reports focusing on Re-ITx. This study aimed to: 1) Describe in detail a single center Re-ITx experience, 2) Identify distinct characteristics of the initial/primary (1º-Tx) vs. Re-ITx, 3) Highlight unique predictors of survival for patients undergoing Re-ITx. Methods: An IRB-approved retrospective analysis of all Re-ITx recipients at a single-center between 1991-2012 was performed. Clinical characteristics of 1º-Tx and Re-ITx were compared using chi-square and t-tests. Survival was computed using Kaplan-Meier methods.  Over 30 variables were analyzed using log-rank test with significance set at P≤0.20.

Results: 23 patients underwent Re-ITx.  Patients were mostly male (83%), Latino (65%), children (74%) (Table 1).{figure1} 1º-Tx was: isolated ITx (8, I-ITx), Liver-ITx (9, L-ITx), multivisceral (1, MVT), modified MVT (2, mMVT), isolated liver transplantation (3, LTx).  The most common cause for 1º-Tx loss was rejection (57%). Mean time from 1º-Tx to Re-ITx was 1.7 ± 1.7 years.  

Significant differences (p≤0.05) between 1º-Tx vs. Re-ITx at the time of transplant included: intubation status, cGFR and type of transplant; variables approaching statistical significance (p≤0.20) were: pre-ITx location, intra-operative blood loss, and requirement for accessory renal transplant.  Median followup time after Re-ITx was 36 mo. Overall 1/3/5 year patient survival following re-ITx was 68/61/50%.  The most common cause of graft loss after Re-Tx was patient death. 4 Re-ITx developed PTLD.

Predictors of patient/graft survival following Re-ITx were:

GRAFT- PRA < 20% (p=0.05),1º-Tx LOS <80 days (p=0.08), no B or T-cell X-match (p=0.15), pediatric age (p=0.16), Tube feeds started < 7 days (p=0.17);

PATIENT- 1º-Tx LOS <80 days (p=0.007), Re-ITx after 2001 (p=0.03), WIT < 1hr (p=0.03), donor spleen transplanted and removed (p=0.12), weight < 20 kg (p=0.19). 

Conclusions: This study analyzes one of the largest experiences with Re-ITx. Re-ITx is a significant undertaking but successful outcomes can be achieved as demonstrated herein. In general, our Re-ITx patients are sicker requiring more specialized hospital care and more careful patient selection. Special focus must be paid to kidney function at time of Re-ITx. Surprisingly, technical factors were not the major cause of failure; instead infection predominated.