Background: Even though graft versus host disease (GVHD) occurs in 50% of patients receiving allogeneic hematopoietic stem cell transplantation, it is a rare complication after solid organ transplantation. Due to the large amount of lymphoid cells, intestinal and multivisceral transplantation triggers the bidirectional exchange of immune cells resulting in graft versus host and host versus graft interaction. Once it occurs, GVHD is associated with high morbidity and mortality after intestinal transplantation. We describe our center experience with GVHD over almost 25 years.

Methods: We retrospectively reviewed 442 intestinal transplants from 1994-2018 at Miami Transplant Institute and recipients were divided into 5 groups depending on the induction immunosuppression used; group 1 (44/442): high dose steroid (34/44), OKT3 (7/44), or cyclophosphamide (3/44); group 2: anti-CD25 (daclizumab or basilixmab) (159/442); group 3: alemtuzumab (113/442); group 4: rabbit antithymocyte globulin (rATG) (34/442); group 5: rATG and rituximab. Types of intestinal transplant included: isolated intestine (I) (n=124), liver-intestine (LI) (n=38), modified multivisceral (MMV) (n=39), and multivisceral (MV) (n=241) allografts.

Results: GVHD occurred in 8.6% (39/442). Actuarial estimates of GVHD free survival at 3, 6, 12, 24 and 60 months in the 5 induction groups were: 92% through all times in group 1; 94%, 88%, 87%, 86% and 86% in group 2; 99%, 99%, 97%, 96% and 96% in group 3; 88% through all times in group 4; 90%, 87%, 86%, 86% and 86% in group 5, respectively. MV and MMV allografts were associated with an increased incidence of GVHD (P= 0.00004) during 60 post-transplant months. Group 3 (Alemtuzumab) was associated with a decreased hazard rate of developing GVHD (P=0.004) but this effect lasted only during the 1st 6 post-transplant months. Graft loss due to GVHD occurred in 31.6% (12/38) with an increased risk in MV and MMV transplant recipients (P=0.05).

Conclusion: MV and MMV transplant recipients experienced increased risk of GVHD related morbidity and mortality while alemtuzumab induction immunosuppression protocol was associated with a decreased risk of GVHD during the 1st 6 post-transplant months.