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THE MORBIDITY arising from the chronic use of .1. anti-rejection medications is an incentive to establish the lowest posSIble level of immunosuppression necessary to maintain stable graft function. The finding that freedom from immunosuppression was sporadically possible in longsurviving recipients of liver allografts and the concurrent evidence that chimerism was uniformly demonstrable in such tolerant patients! have led to a prospective trial of complete drug weaning. In our initial experience, it was shown that significant reductions in medication or their discontinuance could be safely accomplished in liver,: and even in a handful of living-related kidney recipients who have been drug free for as long as 30 years.3 However, the danger of consequent allograft rejection has not been completely assessed and guidelines for judicious weaning need to be clarified. We present here further follow-up on our previously reported weaning trial in liver allograft recipients2 and results from additiona.l patients subsequently entered.

Survival for children is significantly higher than for adults after liver transplantation (LTx).1 A center-specific 20-year retrospective analysis of all pediatric transplant recipients was implemented to determine patient and graft survival, graft survival, and differences in survival related to immunosuppressive protocols.

Although tacrolimus-based immunosuppression has made clinical intestinal transplantation feasible, the risk of the requisite long-term high-dose treatment has inhibited the widespread use of these procedures. 1 Such a risk could be partially eliminated with safe adjustment of the current immunosuppressive management protocol according to the type of intestinal allograft.

CHRONIC rejection (CR) is a significant cause of graft failure after successful liver transplantation and occurs in 2% to 20% of LTx cases under CsA. Up to 70% of chronic rejection occurring under CsA-based therapy may be halted or reversed following initiation of tacrolimus therapy. We analyzed 1048 adult post-LTx patients under tacrolimus in which 5252 liver biopsies were done. The rate of chronic rejection leading to graft loss or death was 1.8% with a mean follow up of 6 years. Another 1.3% had CR on biopsy, but by optimizing their baseline immunosuppression, CR stabilized. The presence of viral infection (HCV, HBV), autoimmune processes (PBC, PSC, AI), and/or the inability to maintain immunosuppression (for life-threatening infection/PTLD/noncompliance of patients) were identified as risk factors. The aim of the present study was to examine the incidence of CR in the pediatric (age 18 years) primary LTx under tacrolimus over the long term, where the incidence of viral hepatitis and autoimmune processes are far less common.

A positive antidonor T-cell lymphocytotoxic crossmatch (X-M) has been shown to have a deleterious effect on graft survival after solid organ transplantation.1–3 This is the first report to address the impact of preformed antidonor IgG lymphocytotoxic antibodies on intestinal allograft rejection and survival.

We previously identified rejection as the most significant risk factor for intestinal allograft survival.1 The reported efficacy of daclizumab (Zenapax. Hoffman-LaRoche) prophylaxis with solid organ transplantation2 triggered its use at our center as induction therapy for intestinal transplantation.

Under tacrolimus-based immunosuppression, long-term rehabilitation has become achievable with intestinal transplantation. 1 Herein, we report our 9-year experience with multivisceral transplantation for patients with diffuse irreversible gastrointestinal diseases.

We have previously estimated a 20% frequency of Epstein–Barr virus (EBV) related post-transplant lymphoproliferative disorders (PTLD) in small bowel allograft recipients. 1 The present study compares rates of PTLD among pediatric and adult recipients of isolated or composite small bowel allografts. We also report PTLD frequency before and after the institution of quantitative EBV monitoring and the use of ancillary donor bone marrow infusion to facilitate microchimerism, both of which began in mid-1994.

There were 34 episodes of documented noncompliance among 28 patients (15 males, 13 females) transplanted between March 1984 and May 1993. The mean age at the time of transplantation was 9 years (range, 2.6 to 16 years). The first episode of noncompliance was diagnosed at a mean age of 14.8 years (range, 10 to 20 years), and a mean of 6.5 years (range, 1.4 to 11.9 years) after transplantation. In those cases in which there was more than one episode of noncompliance, the mean time from the first to the second episode was 2.1 years (range, 0.6 to 3.9 years). At the time of noncompliance, 11 patients were on cyclosporine A (CyA) and 17 were receiving FK 506 (9 of which had been previously converted from CyA). There was a mean of 2.19 (range 0 to 6) episodes of rejection per patient before the diagnosis of noncompliance. Seventy-nine percent (n 5 22) of the noncompliant children had a history of psychiatric/ psychosocial associated factors. Liver biopsy specimens obtained at the time of noncompliance in 18 patients showed acute cellular rejection (n 5 8), hepatitis (n 5 5), hepatitis/rejection (n 5 3), and pericholangitis (n 5 2). Twenty-two patients had reinstitution of their baseline immunosuppressive drugs, FK 506 (n 5 17), and CyA (n 5 5). The remaining six were converted from CyA to FK 506. Four grafts were lost to chronic rejection, and one to rupture of a hepatic artery aneurysm after successful treatment of rejection. Three patients required retransplantation, one of them twice. There were two recurrences of noncompliance after retransplantation. Two patients died, the patient with the ruptured aneurysm and one of the retransplanted patients secondary to chronic rejection.