Experimental short-term immunosuppression after bowel transplantation and donor-specific bone marrow infusion

Hypothesis: We previously showed in a large animal pig model that unmodified donor-specific bone marrow infusion (DSBMI) did not facilitate total bowel engraftment; in contrast, it increased the risks of rejection, infection, and graft-vs-host disease (GVHD) posttransplant. We hypothesize that continuous immunosuppression, in combination with DSBMI, might contribute to - or even trigger - these unwarranted immune responses by both host and graft; therefore, discontinuing immunosuppression might decrease these risks and prolong survival. Methods: Six groups of outbred, mixed lymphocyte culture-reactive pigs underwent a total (small and large) bowel transplant: group 1, nonimmunosuppressed control pigs (n = 5); group 2, nonimmunosuppressed DSBMI pigs (n = 6); group 3, tacrolimus (indefinite) pigs (n = 7); group 4, tacrolimus (indefinite) plus DSBMI pigs (n= 7); group 5, tacrolimus (10 days only) pigs (n = 5); and group 6, tacrolimus (10 days only) plus DSBMI pigs (n = 6). Results: The combination of short-term immunosuppression and DSBMI (group 6) significantly prolonged survival, compared with short-term immunosuppression only (group 5) or DSBMI only (group 2). Short-term immunosuppression and DSBMI (group 6) did not prolong overall survival, compared with indefinite immunosuppression with (group 4) or without (group 3) DSBMI: survival rates at 7, 14, and 28 days posttransplant were 100%, 100%, and 67% in group 6; 100%, 100%, and 71% in group 3; and 100%, 67%, and 47% in group 4 (P = .14). Short-term immunosuppression and DSBMI (group 6) increased the incidence of rejection, infection, and GVHD, compared with indefinite immunosuppression without (but not with) DSBMI. Conclusions: Short-term immunosuppression and DSBMI did not prolong survival and did not reduce the incidence of death from rejection, infection, or GVHD, compared with indefinite immunosuppression without DSBMI. But short-term immunosuppression and DSBMI resulted in a lower incidence of death from infection and GVHD, compared with indefinite immunosuppression and DSBMI. When immunosuppression was discontinued 10 days posttransplant, the effect of DSBMI was insufficient to avert death from rejection. Clinical Relevance: The clinical results of bowel transplantation trail those of other solid organ transplants. It reduced the rates of infection and GVHD. Our study shows that systemically infused donor-specific bone marrow with short-term or indefinite immunosuppression does not improve outcome after bowel transplantation. It seems necessary to modify the time, dosing, routing, and/or composition of donor-specific bone marrow before it can be successfully used in clinical bowel transplantation.