LAUSR

Introduction: Long term graft dysfunction requiring parenteral support has been frequently described post intestinal transplant. Diarrhea, dehydration and weight loss are the most common symptoms. Chronic rejection may be the cause, but diagnosis is very difficult to make. Teduglutide is a glucagonlike peptide 2 analogue that restores intestinalfunctional integrity by promoting growth of themucosa, increasing fluid and nutrient absorption and slowing the transit. It is commonly used for patients with short bowel syndrome. Methods: To describe our first experience with the use of teduglutide for the treatment of chronic graft dysfunction after intestinal transplantation. This report, to the best of our knowledge, is the first time teduglutide is ever used in an intestinal transplant recipient. Results: A 68 years old female, 5 years post intestinal transplant due to volvulus, presented with symptoms of graft dysfunction. Diarrhea, dehydration, renal failure and weight loss led to frequent admissions. Extensive worked upwas performed. No signs of acute cellular rejection or infectionswere identified. Bacterial overgrowth was ruled out. Pancreatic exocrine function was normal. Patient did not have any donor specific antibody. Multiple attempts to control the symptoms (anti-diarrheal medications, binding agents, pancreatic enzymes, different diets) had failed. Patient was eventfully discharged on parenteral hydration (2 liters/day). Episodes of line infection became routine. Patient satisfaction was very low due to social limitation. Around 10 episodes of diarrhea limited daily activities. Teduglutide was started daily after colonoscopy ruled out presence of polyps. Improvement of the graft function was immediately observed with decrease of the evacuations from 10 to 1 to 2 a day with formed stools. Other anti-diarrheal medications were stopped. Hydration was weaned over 3 months due to initial poor patient intake and line was removed. Creatinine and BUN returned to the baseline with improvement of the GFR. Pre-albumin normalized. Interestingly, IgG levels which were initially noted to be low, increased to normal levels likely due to resolution of protein enteropathy. Citrulline levels more than doubled. Minor edema in the legs was observed in the first month of treatment. Surveillance with colonoscopy performed every 6 months without any abnormal findings. Patient remains free of any parenteral support 18 months after treatment commence. Discussion:High patient satisfaction and great improvement in quality of life is associated with resolution of the previous symptoms. Risk of the development of polyps outweigh the many hurdles of parenteral support. Teduglutide may become a therapeutic option on the treatment of intestinal failure not only pre but also post transplant.