Agustina Zambernardi¹, Gabriel Gondolesi¹, Martín Rumbo¹, Ana Cabanne², Maria Inés Martinez¹, Hector Solar¹, Carolina Rumbo¹

¹Instituto de Trasplante Multiorganico Unidad de Rehabilitación, Nutrición y Transplante Intestinal, Hospital Universitario - Fundación Favaloro, Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina; ²Anatomia Patologica, Hospital Universitario - Fundación Favaloro, Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina

Introduction: Exfoliative rejection (ExR) is a severe complication after intestinal transplant (ITx). The assessment and follow up of intestinal mucosa histology is restricted to a small area reached by endoscopy. There is no biochemical marker capable to reflect the total extension and severity of intestinal mucosa damage.  We aim to evaluate the value of serum albumin (SA) as a parameter of graft damage and recovery during ExR.

Patients and Methods: This is a retrospective review of ExR episodes in a cohort of ITx patients. The diagnosis of ExR was based on the histology criteria established in the “Pathology Workshop, VIIIth International Small Bowel Transplant Symposium, Miami, Florida”. Additional laboratory data and clinical variables (parenteral nutrition (PN) composition, use of albumin infusion, patient weight and infectious intercurrences, liver synthetic function, kidney function) were considered to rule out SA variations due to causes other than epithelial damage. SA levels were collected at least twice a week after the initial stabilization of the patient to avoid inaccurate values due to shock or dehydration. Clinical recovery (CR) was established when enteral nutrition was restarted and ostomy/stool output decreased to normal range (< 40 ml/kg/day in children and <1500 ml/day in adults). Histological recovery (HR) was considered after 2 consecutive normal biopsies.

Results: 7 episodes of ExR were diagnosed in 7/29 ITX recipients, (2 adults and 5 children). Four ExR episodes occurred early after transplant, while the patients were still admitted (GpA) and 3 in the ambulatory setting, more than 2 years after ITx (GpB). In both groups the SA reached a minimum average of 1.7g/dl (SD= 0.5) (normal values 3.5-5.2 g/dl), being lower in GpA (p<0.05). CR occurred in an average of 21 days in GpA and 41 days in GpB (p=0.08). The minimum time from diagnosis of ExR to normalization of SA levels was 30 days (GpA) and 60 days (GpB), except for one patient from GpB that remained dependent of PN, with subnormal values of SA level and was listed for re-transplantation. HR was reached in 32 days and 260 days for GpA and GpB respectively (p<0.02). In all cases normalization of SA occurred between CR and HR.

Conclusion: 1) SA might be used as a biochemical indicator of intestinal recovery during treatment of ExR. 2) SA seems to recover faster in early ExR and might be used as predictor of functional outcome.