Chronic allograft enteropathy

Curren t im m unosuppression has made small bowel transplantation the standard of care for patients with short bowel syndrome who face complications of total parenteral nutrition (TPN). With standardization and refinement of operative techniques and improvements in rates and outcomes of acute cellular rejection, attention is rightfully turning to late outcomes and quality of life of long-term survivors. Despite seemingly adequate maintenance therapy, chronic rejection affects the long-term outcome post intestinal transplantation and can lead to graft loss with attendant morbidity and even mortality. Pari passu with this, comes the issue of retransplantation. The findings of chronic rejection are subde in mucosal (endoscopic) biopsies and a clinical presentation of worsening nutritional status in a patient who was previously doing well, coupled with a high index of suspicion, can precede the pathologic findings of this entity. The diagnosis is more reliably made on full-thickness biopsies, generally obtained after exploratory laparotomy for obstructive symptoms, or on explant of the whole allograft. The final consequences of chronic rejection are graft loss and resumption of TPN and/or retransplantation. In this chapter, we will discuss chronic rejection in small bowel transplantation, from the clinician s perspective and will try to show the many hurdles faced during the evaluation and treatment of this complex issue.