Introduction: Exfoliative rejection (ER) of the intestinal graft is associated with significant fluid and electrolyte losses, recurrent sepsis due to microbial translocation and often leads to graft enterectomy, re-transplant or death. The majority of previously reported cases or case series of ER are in paediatrics.

Methods: We present here a case series of ER in adults from a single centre in the UK over the time period 2007-2018. This is a retrospective review of a database containing patient demographics, endoscopy and histology findings and outcomes. ER was diagnosed based on endoscopic findings of widespread areas of denuded mucosa.

Results: 84 patients were transplanted in the specified time period: 34 MVT, 13 Liver/Intestine, 11 MMVT, 25 Intestine only. 7 patients (8.3%) experienced an episode of ER. Precipitating reasons for ER were immunosuppression switch (2), non-compliance (2), low immunosuppression levels because of comorbidity (2) and in one case the patient had concurrent severe adenovirus infection. It is not clear whether the viral infection triggered rejection.

All patients received pulsed steroids. 4/7 patients received second line treatment with Alemtuzumab (1) or Anti-Thymocyte Globulin (3). 3 patients underwent repeat transplant of which one had graft enterectomy 3 weeks prior to the second transplant. 2 further patients had limited graft resection due to strictures and had subsequent full graft function. The only death related to ER occurred in the patient with concurrent adenovirus who developed a recurrence of this following re-transplant. All patients required parenteral nutrition and often additional fluids and electrolyte replacement due to the large volume stomal losses (often in excess of 5 litres per day) until recovery or re-transplant.

Conclusion: Exfoliative rejection in this case series frequently occurred in the setting of overall lower immunosuppression than would be desirable. In some cases this was unavoidable, but every effort should be made to support patient adherence to treatment and to provide general psychological support. Historically, switching immunosuppression has been a potential trigger for severe/exfoliative rejection in our unit. Protocols are now in place for managing switches and since these have been instigated, no episodes of rejection have occurred in this context. Reducing immunosuppression due to co-morbidity is always a difficult decision and should be made within a full multidisciplinary setting.