Role of Surveillance Biopsies in Monitoring Recipients of Pancreas
Alone Transplants
L.W. Gaber, R.J. Stratta, A. Lo, M.F. Egidi, M.H. Shokouh-Amiri, H.P. Grewal, T.A. Kizilisik,
and A.O. Gaber
A
PREVIOUS STUDY by Stratta et al examined the
utility of prospective monitoring of recipients of
solitary pancreas transplants with surveillance biopsies and
demonstrated that such a protocol is safe and effective.
1
Recent changes in immunosuppressive regimens and surgi-
cal techniques have had a significant impact on the man-
agement and outcomes of pancreas transplant recipients.
We adopted a protocol of scheduled routine biopsies in
managing solitary pancreas transplant recipients with por-
tal-enteric drainage and tacrolimus (TAC)- and mycophe-
nolate mofetil (MMF)-based immunosuppression. We re-
port herein our findings in these surveillance biopsies and
their correlation with the clinical course of pancreas alone
(PA) recipients.
METHODS
From March 1997 to December 1999, we implemented a protocol
of surveillance biopsies to monitor recipients of solitary pancreas
allografts. The first biopsy was performed at 2 to 3 weeks post-
transplant. If a subclinical rejection was diagnosed, a follow-up
biopsy was performed 2 to 3 weeks following treatment regardless
of biochemical measures of graft function, followed by monthly
biopsies for 3 to 6 months depending on clinical status and biopsy
results. Nine PA recipients underwent a total of 55 transabdominal,
percutaneous, ultrasound-guided biopsies, 29 of which were sur-
veillance biopsies performed in the absence of pancreatic dysfunc-
tion.
2
Three biopsies were excluded from the analysis due to inade-
quate sample size; the other 26 biopsies form the basis of this
report. Biopsy findings were reported according to the University
of Maryland Grading System.
3
The biopsies were classified into
three primary categories based on the diagnosis: (1) negative for
rejection; (2) inflammation of undetermined significance (IUDS);
and (3) rejection. Biopsy findings were correlated to serum amy-
lase, lipase, fasting glucose, creatinine, and 12-hour trough TAC
levels at the time of biopsy.
Patient demographics and clinical outcomes were also evaluated.
All patients received induction therapy with either OKT3, thymo-
globulin, or daclizumab and maintenance therapy with TAC,
MMF, and steroids.
RESULTS
Demographic and clinical characteristics of PA recipients
are listed in Table 1. Surveillance biopsies were performed
between days 12 and 150 (mean 60 36 days) posttrans-
plant. At the time of biopsy, the serum amylase ranged from
30 to 382 U/L (mean 66.3 74 U/L), serum lipase ranged
from 17 to 848 (mean 97.2 162 U/L), and fasting glucose
ranged from 64 to 186 mg/dL (mean 98.2 30 mg/dL).
Acute rejection (grade III) was diagnosed in five (19%)
of the surveillance biopsies. The histologic diagnoses on the
biopsies were as follows: normal pancreas (14 biopsies);
mild focal acute pancreatitis (one biopsy); IUDS/grade I
infiltrate (six biopsies); grade IL-V acute rejection (five biop-
sies). The five episodes of acute rejection were diagnosed in
three patients; all were treated with antirejection therapy. One
patient developed a grade III rejection on posttransplant day
12. The biopsy showed mild septal inflammation that was
associated with venulitis and multifocal intralobular mononu-
clear inflammatory infiltrates. Another patient had two rejec-
From the Departments of Pathology (L.W.G.) Surgery (R.J.S.,
M.H.S.-A., H.P.G., T.A.K., A.O.G.) Pharmacy (A.L.) and Medicine
(M.F.E.), University of Tennessee-Memphis, Memphis, Tennes-
see, USA.
Address reprint requests to Lillian W. Gaber, MD, Department
of Pathology, University of Memphis-Memphis, 582-M Baptist
Memorial Hospital, Memphis, TN 38163.
Table 1. Demographic and Clinical Characteristics
Age (years) 36.2 7.1 (range 25– 49)
Gender (male/female) 5/4
Race (Caucasian/African American) 9/0
Antilymphocyte induction
OKT3 3
Thymoglobulin 3
Daclizumab 3
Maintenance immunosuppression
(prednisone, tacrolimus,
mycophenolate mofetil)
9
Negative PRA at transplantation 9
AB mismatch (2) 7
2 DR mismatch 3
CMV status (donor/recipient)
CMV +/-; CMV +/+;
CMV -/+; CMB -/-
4;3;1;1
Donor age (y) 26 10 (range 17– 45)
Cold ischemia time (h) 14.7 3.5 (range 9 –21)
Results are mean SD.
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Transplantation Proceedings, 33, 1673–1674 (2001)
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