Intestinal Transplantation under Tacrolimus Monotherapy after Perioperative Lymphoid Depletion with Rabbit Anti-Thymocyte Globulin (Thymoglobulin®) |
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Authors: | Jorge Reyes George V Mazariegos Kareem Abu-Elmagd Camila Macedo Geoffrey J Bond Noriko Murase John Peters Rakesh Sindhi Thomas E Starzl |
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Institution: | Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Thomas E. Starzl Transplantation Institute, USA. |
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Abstract: | Modifications in the timing and dosage of immunosuppression can ameliorate the morbidity and mortality that has prevented widespread use of intestinal transplantation (ITx) in children. Thirty-six patients receiving ITx, aged 5 months to 20 years were given 2-3 mg(kg of rabbit anti-thymocyte globulin (rATG, thymoglobulin) just before ITx, and 2-3 mg(kg postoperatively (total 5 mg(kg). Twice daily doses of tacrolimus (TAC) were begun enterally within 24 h after graft reperfusion with reduction of dose quantity or frequency after 3 months. Prednisone or other agents were given to treat breakthrough rejection. After 8-28 months follow-up (mean 15.8 +/- 5.3), 1- and 2-year patient and graft survival is 100% and 94%, respectively. Despite a 44% incidence of acute rejection in the first month, 16 of the 34 (47%) survivors are on TAC (n = 14) or sirolimus (n = 2) monotherapy; 15 receive TAC plus low dose prednisone; one each receive TAC plus sirolimus, TAC plus azathioprine and TAC plus sirolimus and prednisone. There was a low incidence of immunosuppression-related complications. This strategy of immunosuppression minimized maintenance TAC exposure, facilitated the long-term control of rejection, decreased the incidence of opportunistic infections, and resulted in a high rate of patient and graft survival. |
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Keywords: | Anti-thymocyte globulin intestinal failure intestinal transplantation pediatric transplantation short gut syndrome tacrolimus |
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