Intestinal and Multivisceral Transplantation Immunosuppression Protocols—Literature Review A.P. Trevizol, A.I. David, E.R. Dias, D. Mantovani, R. Pécora, and L.A.C. D’Albuquerque ABSTRACT Introduction. Currently the most used techniques for small bowel transplant are isolated intestinal transplantation, multivisceral transplantation (MVT), and modified multivisceral transplantation. One important factor is early diagnosis of acute cellular rejection (ACR). In addition, improvements in immunosuppression have recently reduced the number and enhanced treatment of ACR episodes, enabling graft recovery. Objective. We analyzed immunosuppression protocols of leading transplantation centers in the last 5 years. Method. We reviewed papers published in PubMed from major multivisceral and intestinal transplantation centers from 2006 to 2010 in adult recipients. The 211 adults transplanted in seven centers were divided into three groups according to the immuno- suppression protocol used: protocol 1: daclizumab induction with tacrolimus and steroid maintenance; protocol 2: alemtuzumab and tacrolimus; and protocol 3: thymoglobulin and rituximab and tacrolimus. Results. Protocol 2 showed the lowest rate of ACR (34%). Protocols 1 and 3 displayed 54% and 48% ACR rates; respectively. However, protocol 1 patients developed only mild ACR, whereas those in protocols 2 and 3 developed moderate ACR in 26.3% and 11.7%, and severe ACR in 7.9% and 47% of cases, respectively. The infection rate was considerably lower in protocol 3 (7.4%). Protocols 1 and 2 showed infection rates of 62.5% and 52%, respectively. One-year patient survival rates were 70%, 79% and 81%, respectively. Three-year patient survival rates were 62%, 56%, and 78% for protocols 1, 2 and 3, respectively. Conclusion. Protocol 2 was the strongest immunosuppressive regimen capable of reducing ACR rates when compared with the other protocols, but the strong effect resulted in high infection rate that impacts 1-year patient survival. Protocol 3 seems to be the best available one balancing ACR and infection rates. I NTESTINAL (IT) and multivisceral (MVT) transplan- tations are the only curative treatments for patients who have failure of the intestinal tract associated with life- threatening complications due to parenteral nutrition. The first human bowel transplantation was performed in 1964 at the Boston Floating Hospital. 1 Nearly 20 years later, the first human multivisceral transplant was performed at the University of Pittsburgh. 2 The immunosuppressive protocol included cyclosporine; graft rejection and fatal infection blocked progress of the endeavor, which became feasible after the advent of tacrolimus in 1989. 3 Intestinal expres- sion of histocompatibility antigens, resident immune cells and microorganisms, as well as innate immunity make graft rejection and infection bigger problems than those observed with other solid organ transplantations. 4,5 The immunosuppression protocols for IT and MVT must be strong to prevent acute cellular rejection (ACR), thus increasing the risk for infection, which is the main cause for From the Faculdade de Ciências Médicas da Santa Casa de São Paulo (A.P.T., E.R.D., D.M.), and the GI Transplant Program, Hospital das Clinicas/FMUSP (A.I.D., R.P., L.A.C.D.), São Paulo, Brazil. Address reprint requests to André Ibrahim David, Rua Pam- plona 1808, apto 52, Jardim Paulista, São Paulo, Brazil. E-mail: andredavidmd@gmail.com © 2012 by Elsevier Inc. All rights reserved. 0041-1345/–see front matter 360 Park Avenue South, New York, NY 10010-1710 http://dx.doi.org/10.1016/j.transproceed.2012.07.016 Transplantation Proceedings, 44, 2445–2448 (2012) 2445