Diagnosis and Treatment of Pancreas Rejection

Abstract

Despite significant improvement in pancreas allograft survival, rejection of the pancreas remains a major clinical problem. In addition to cellular rejection of the pancreas, antibody-mediated rejection of the pancreas is now a well-described entity. The 2011 Banff update established comprehensive guidelines for the diagnosis of acute and chronic AMR. The pancreas biopsy is critical in order to accurately diagnose and treat pancreas rejection. Other modes of monitoring pancreas rejection we feel are neither sensitive nor specific enough. In this review, we examine recent advances in the diagnosis and treatment of pancreas rejection as well as describe practical diagnostic and treatment algorithms.

Keywords: Diagnosis; Pancreas rejection; Treatment.

Fig. 1

Temporal relationship of elevated pancreas enzymes to etiology. Surgical complications typically present early in the postoperative course, whereas rejection most commonly presents later. “Other” includes possible causes such as transplant pancreatic duct stricture, native pancreatitis, IPMN or cancer in pancreas transplant or native pancreas, and penetrating ulcer. Of note, although complete graft thrombosis can present as increased pancreatic enzymes, in our experience, this is a very uncommon presentation, and when most grafts thrombose, very limited increases in enzymes are seen if at all. Relative probability on the Y-axis does not represent the overall probability or incidence of this complication; instead, it strives to convey the relative probability that these diagnoses are associated with elevated pancreatic enzymes. Abbreviations: ACR/AMR acute cellular rejection/antibody-mediated rejection, Ent/Pa Leak enteric or pancreatic leak, SBO small bowel obstruction

Fig. 2

The University of Wisconsin Diagnosis and Treatment Algorithm Abbreviations: DSA donor-specific antibody, ACMR acute cell-mediated rejection, aAMR acute antibody-mediated rejection, cAMR chronic antibody-mediated rejection, ATG anti-thymocyte globulin, IVIg intravenous immunoglobulin, PP plasmapheresis. [(Published in Trends in Transplantation, © Permanyer Publications) 2].