Systematic Protocol Biopsy of the Duodenal Graft for Surveillance after Pancreas Transplantation

Abstract

Introduction: We present data on serial protocol biopsies (px) of the duodenal graft by double-balloon enteroscopy (DBE) for surveillance of rejection and local CMV infection in patients undergoing either single pancreas (SPT) or combined pancreas and kidney transplantation (SPK). Methods: Between August 2009 and December 2011, 39 pancreas transplantations (SPK n= 31; SPT n= 8) were performed. All patients underwent consecutive px of the duodenal graft at 1, 3, 6 and 12-month post-transplant. Thereafter, duodenal-px was continued yearly and/or on-demand basis. Rejection was evaluated according to the Banff criteria for small bowel allografts. All samples were immunostained for focal cytomegalovirus (CMV) infection. Results: Patient and survival rate for the study cohort were 100%. Overall 86 mucosal px of the duodenal graft were obtained in 36 patients. No procedure-related complications were observed. DBE was feasible in 90% of the study cohort. In 7 out of 39 patients (17.9%) (SPK n= 4; SPT n=3) rejection was diagnosed in the duodenal graft. All patients in the SPK group presented also rejection in the kidney graft, either simultaneously (n= 2) or previous to the duodenal px (n= 2, 14 and 50 days pre-duodenal-px). In SPT group, subclinical rejection was diagnosed in 3 of 8 patients. Local CMV-infection was detected in 5 patients (13%) (SPK n= 3; SPT n= 2). In 1 patient with focal CMV infection, spontanuous perforation of the duodenal graft was observed at 1-month. Subsequent duodenal px at 1-month post-treatment showed reversal of both rejection episodes and focal CMV-infections. Conclusion: Serial protocol px of the duodenal segment of the pancreas graft by DBE is safe and might represent an effective method for surveillance of both rejection and focal CMV-infection after clinical pancreas transplantation.