Immunosuppression

The enormous amount of lymphatic tissue transplanted together with the bowel, be it in the form of mesenteric lymph nodes or mucosa-associated lymphatic tissue, is responsible for the heightened immunogenicity of an intestinal graft over other solid organs. This is the reason why recipients of a bowel transplant require more immunosuppression as compared to recipients of a kidney or heart transplant.

Following induction with lymphocyte depleting antibodies such as antithymocite globulin, Campath 1H (Genzyme, MA, USA), OKT3 (Ortho Biotech, NJ, USA) or with monoclonal anti-interleukin 2 (IL-2) receptor antibodies. Maintenance immunosuppres-sion is usually based on the calcineurin inhibitor tacrolimus together with other anti-proliferative agents such as mycophenolate mofetil and steroids. There is a trend to minimize the use of the latter. The combination of tacrolimus and sirolimus seems not to have additional benefit over tacrolimus alone. Antibody preconditioning seems to allow less potent subsequent maintenance immunosuppression. Antibodies, however, are occasionally associated with severe adverse reactions caused by cytokine release [14,15].

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