LOW IMMUNOLOGIC FAILURE RATE OF SOLITARY PANCREAS TRANSPLANTS WITH PORTAL VENOUS DRAINAGE

Abstract

92 Despite the potential physiologic benefits of portal venous drainage and enteric exocrine drainage, most whole organ pancreas transplants in the US are done with systemic venous drainage and drainage of exocrine secretions into the bladder. Inability to monitor for rejection is often cited as the reason to avoid portal and enteric drainage, especially for solitary pancreas transplants. Since December 1996, we have performed 32 solitary pancreas transplants (PA) with both portal venous drainage and enteric exocrine drainage. Of the 32 PA, 20 patients (62.5%) received a pancreas after a kidney (PAK), and 12 patients (37.5%) had a pancreas transplant alone (PTA). Eight (25%) of the 32 PA were re-transplants, and the mean ABDR mismatch was 4.3±0.28(SE). Results Pancreas graft loss has occurred in 6 patients (19%). Of the 6 pancreas graft losses, 3 (9.4%) were early (2 early thromboses and 1 deep wound infection), and 3 (9.4%) were late (1 late thrombosis associated with acute and chronic rejection, 1 death with function due to stroke, and 1 death due to post-transplant lymphoproliferative disorder [PTLD]). Overall graft survival at 1 year is 79.7%, and is 94.7% with non-immunologic causes of graft failure censored. Two PAK kidneys have been lost to patient death (stroke and PTLD). TableTableSeven (21.9%) of the 32 PA have been treated for 10 rejection episodes [Table 2]. Of the 10 rejection episodes, 6 (60%) were biopsy proven, and 4 (40%) were presumptive acute rejections based on serum amylase, serum lipase, and patient history. Treatment reversed hyperamylasemia and maintained euglycemia in 100%. 13 episodes of elevated serum amylase and serum lipase were evaluated by biopsy. 3 open biopsies were done because patients needed laparotomy for other reasons. The other 10 biopsies were obtained by ultrasound or CT guidance. Biopsy (Bx) revealed acute rejection (AR) in 8 (61.5%) of the 13 cases. One patient who had 2 positive biopsies (both grade II AR) did not receive anti-rejection treatment because of concomitant infection. A subsequent percutaneous biopsy in this patient showed resolution of the AR, and the graft continues to function. TableTableConclusions Solitary pancreas transplantation, using portal venous drainage and enteric exocrine drainage, can achieve pancreas graft survival rates similar to simultaneous kidney pancreas transplantation. Inability to monitor for rejection was not a significant problem. Only 1 (3%) of 32 pancreas transplants was lost to rejection. Elevation of serum amylase and serum lipase is sensitive, but nonspecific. Rejection on biopsy was found in only 61.5% of the cases where these enzymes were elevated, and needless anti-rejection therapy was avoided by the successful application of percutaneous biopsy.