Weiner Joshua, Llore Nathaly, Ormsby Dylan, Fujiki Masato, Segovia Maria Cristina, Obri Mark, Jafri Syed-Mohammed, Liggett Jedson, Kroemer Alexander H K, Matsumoto Cal, Moon Jang, Di Cocco Pierpaolo, Selvaggi Gennaro, Garcia Jennifer, Ganoza Armando, Khanna Ajai, Mazariegos George, Wendel Danielle, Reyes Jorge
Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, NY.
Department of Surgery, Cleveland Clinic, Cleveland, OH.
Transplant Direct. 2023 Aug 24;9(9):e1512. doi: 10.1097/TXD.0000000000001512. eCollection 2023 Sep.
Unlike other solid organs, no standardized treatment algorithms exist for intestinal transplantation (ITx). We established a consortium of American ITx centers to evaluate current practices.
All American centers performing ITx during the past 3 y were invited to participate. As a consortium, we generated questions to evaluate and collect data from each institution. The data were compiled and analyzed.
Ten centers participated, performing 211 ITx during the past 3 y (range, 3-46; mean 21.1). Induction regimens varied widely. Thymoglobulin was the most common, used in the plurality of patients (85/211; 40.3%), but there was no consensus regimen. Similarly, regimens for the treatment of acute cellular rejection, antibody-mediated rejection, and graft-versus-host disease varied significantly between centers. We also evaluated differences in maintenance immunosuppression protocols, desensitization regimens, mammalian target of rapamycin use, antimetabolite use, and posttransplantation surveillance practices. Maintenance tacrolimus levels, stoma presence, and scoping frequency were not associated with differences in rejection events. Definitive association between treatments and outcomes, including graft and patient survival, was not the intention of this initial collaboration and is prevented by the lack of patient-level data and the presence of confounders. However, we identified trends regarding rejection episodes after various induction strategies that require further investigation in our subsequent collaborations.
This initial collaboration reveals the extreme heterogeneity of practices among American ITx centers. Future collaboration will explore patient-level data, stratified by age and transplant type (isolated intestine versus multivisceral), to explore the association between treatment regimens and outcomes.
与其他实体器官不同，肠道移植（ITx）不存在标准化的治疗方案。我们成立了一个美国肠道移植中心联盟来评估当前的实践情况。
邀请了过去3年中所有开展肠道移植的美国中心参与。作为一个联盟，我们提出问题以评估并从每个机构收集数据。对数据进行汇总和分析。
10个中心参与了研究，在过去3年中进行了211例肠道移植（范围为3 - 46例；平均21.1例）。诱导方案差异很大。胸腺球蛋白是最常用的，多数患者使用（85/211；40.3%），但没有一致的方案。同样，各中心在治疗急性细胞排斥、抗体介导的排斥和移植物抗宿主病的方案上也有显著差异。我们还评估了维持免疫抑制方案、脱敏方案、雷帕霉素靶蛋白使用、抗代谢物使用以及移植后监测实践的差异。他克莫司维持水平、造口情况和内镜检查频率与排斥事件的差异无关。本次初步合作并非旨在确定治疗与包括移植物和患者存活在内的结局之间的确切关联，且由于缺乏患者层面的数据和存在混杂因素而无法做到。然而，我们确定了各种诱导策略后排斥发作的趋势，需要在后续合作中进一步研究。
本次初步合作揭示了美国肠道移植中心实践的极端异质性。未来的合作将探索按年龄和移植类型（孤立肠移植与多脏器移植）分层的患者层面数据，以探讨治疗方案与结局之间的关联。
