Paediatric intestinal transplantation in the modern era: King’s College Hospital Experience
Eirini Kyrana1, Anil Dhawan1, Babu Vadamalayan1, Hector Vilca-Melendez1, Nigel Heaton1, Jutta Koglmeier2, Jonathan Hind1
1Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, United Kingdom; 2Gastroenterology and Nutrition Centre, Great Ormond Street Hospital, London, United Kingdom
Introduction
We established an intestinal transplant service in 2009 in collaboration with a tertiary intestinal rehabilitation centre (Great Ormond Street Hospital) to complement surgical and medical strengths of both units. We report our 4 year experience.
Results
From August 2009- February 2013 10 children (5 male) underwent transplantation at median age 5 years (range 0.5-16). Diagnoses: short gut syndrome (gastroschisis (3), strangulated diaphragmatic hernia (1)), Chronic intestinal pseudo-obstruction (3), intestinal lymphagiectesia (1), microvillous inclusion disease (1) and antenatal midgut volvulus with biliary atresia splenic malformation (1). 8 received isolated small bowel (SB), 2 combined liver and SB.
Immunosuppression: ATG was given to the donor in the first 4 transplants. All had basiliximab induction with Tacrolimus and prednisolone maintenance. Sirolimus was added to all isolated bowel transplant recipients after 1 month but stopped in 7 of 8 due to neutropenia. 1 on azathioprine. 3 patients were given infliximab due to ongoing graft inflammation without apoptosis. 1 improved after 2 doses, 2 improved and remain on 8 weekly doses.
Complications:
Two patients developed severe acute cellular rejection treated with ATG. One responded, one died from sepsis after graft removal.
4 patients developed post transplant lymphoproliferative disease. All were treated successfully. Three with rituximab, one with chemotherapy.
One patient developed severe adenovirus infection. One had cryptosporidium requiring short-term parenteral nutrition.
No episodes of GvHD.
After a median follow-up of 2.5 years (range 0.5-3.5) 9 patients are at home with their original graft and have returned to nursery, school or work. 7 take full enteral feeds, 2 have 30% calorie requirement parenterally (both weaning). 1 patient died at 8 months post transplant.
Conclusion:
An intestinal transplantation programme set up in units with liver transplant and intestinal rehabilitation experience can achieve excellent results comparable to large centres.