Calicivirus enteritis in an intestinal transplant recipient.

Protracted diarrhea of uncertain etiology is a significant problem following intestinal transplantation. We report an infant who developed severe secretory diarrhea 178 days after intestinal transplantation that persisted for more than 120 days. Repeated allograft biopsies demonstrated only nonspecific inflammation. Enzyme immunoassay (for rotavirus), culture, and reverse transcription polymerase chain reaction [calicivirus (Norwalk-like virus)] were used to identify the allograft viral infection. A heavy density of calicivirus RNA nucleotide sequences (genogroup II, strain Miami Beach) was isolated from the jejunal and ileal allograft. Following a reduction in immunosuppressive therapy, diarrhea and enteritis remitted in association with the disappearance of all calicivirus RNA sequences. Calicivirus may cause severe allograft dysfunction in intestinal transplant recipients.

Intestinal transplantation before and after the introduction of sirolimus.

INTRODUCTION: Small bowel transplantation has been limited by high rates of rejection and graft loss. In June 2000, we began using sirolimus, an immunosuppression agent with proven efficacy in kidney transplantation. We reviewed results among intestinal transplant recipients before and after the introduction of sirolimus. METHODS: Thirty-one intestinal transplants were performed in 29 patients at our center between July 1998 and April 2001. All patients were followed for at least 30 days posttransplant. In the first 19 transplants (group 1), patients received tacrolimus, steroids, and antibody induction therapy (either daclizumab or OKT3). In the next 12 consecutive transplants (group 2), patients received tacrolimus, steroids, basiliximab, and sirolimus. RESULTS: Eighteen children (7 males and 11 females, mean age 2.1+/-2.2 years) and 11 adults (9 males and 2 females, mean age 38.1+/-12.4 years) underwent transplantation. All patients survived transplantation. The overall reoperation rate was 1.7 procedures per patient in group 1 and 1.1 procedures per patient in group 2. The most common indications were abscess (n=7), planned second look (n=7), leaks/fistulas (n=6), dehiscence (n=6), obstruction (n=4), ischemic bowel (n=3), perforations (n=3), stomal complications (n=3), and graft removal (n=3). The incidence of biopsy-proven rejection in the first 30 days was 73.7% in group 1 and 16.7% in group 2 (P<0.002). Sirolimus was temporarily held or discontinued in 66.7% of patients. Actuarial 1-year graft survival was 91.7% with sirolimus and 57.9% without sirolimus (P<0.04). Actuarial 1-year patient survival was 91.7% with sirolimus and 79% without sirolimus (P=0.12). CONCLUSIONS: An immunosuppressive regimen that includes sirolimus has improved graft survival. Furthermore, this regimen has significantly decreased the incidence of early rejection and has eliminated early graft loss caused by fulminant rejection.

Recurrent portal hypertension after composite liver/small bowel transplantation.

Late technical complications of composite liver/small bowel transplantation procedures are often complex and have not been well defined. Here we describe the unusual presentation and management of two cases of recurrent thrombocytopenia due to hypersplenism resulting from portacaval shunt stenosis. Both patients presented with portal hypertension late after composite liver/small bowel transplantation. One patient presented with recurrent bouts of upper gastrointestinal hemorrhage and was ultimately found to have a stenosis of her native portacaval shunt. After unsuccessful balloon dilatation of the anastomosis, a successful side-to-side distal splenorenal shunt was performed. The second patient presented with severe thrombocytopenia, the etiology of which was determined to be a short segment occlusion of the inferior vena cava between the native portacaval shunt and the piggyback outflow anastomosis of the liver graft. Total caval occlusion prevented balloon dilatation; the patient was relisted for transplantation but died of chronic rejection four months later. Recurrent portal hypertension is challenging in patients who have had combined liver/small bowel transplantation. Surgeons performing intestinal transplantation need to be increasingly aware of these possible late complications.