Pancreas Transplant Recipients Research Articles

Conservative Pancreas Graft Preservation at the Extreme.

Because of the value some patients place in remaining insulin-independent after pancreas transplantation, they may be reluctant to undergo graft pancreatectomy, even in the face of extreme complications, such as graft thrombosis and duodenal segment leak. Partly, for this reason, a variety of complex salvage techniques have been described to save the graft in such circumstances. We report a case of a series of extreme complications related to a leak from the duodenal segment after a simultaneous pancreas and kidney transplant. These included infected thrombosis of the inferior vena cava associated with a graft venous thrombosis and a retroperitoneal fistula. The patient retained graft function with insulin independence and repeatedly declined graft pancreatectomy against the advice of the transplant team. Conservative treatment with percutaneous drainage, antibiotics, and anticoagulation was eventually successful. This outcome is unique in our experience and may be instructive to teams caring for pancreas transplant recipients.

Prolonged norovirus infection after pancreas transplantation: a case report and review of chronic norovirus

Norovirus is a major cause of self-limited gastroenteritis worldwide. Prevention and treatment are thwarted by rapid viral evolution, and thus supportive care remains the mainstay of therapy. Chronic infection in immunocompromised hosts is increasingly described. We report a case of norovirus infection lasting 2543 days in a pancreas transplant recipient. Serial fecal specimens were obtained, from which a map of genetic relatedness was derived. The clinical course was complicated by renal failure that progressed to end-stage renal disease. Minimization of immunosuppression was associated with resolution of the infection. Subsequently, the patient experienced a suspected allograft rejection that did not compromise pancreas function. The patient later underwent living-related renal transplantation without recurrence of enteritis.

Incidence and outcomes of cytomegalovirus in pancreas transplantation with steroid-free immunosuppression.

Cytomegalovirus (CMV) is a common opportunistic infection encountered after pancreas transplantation. The records of 407 pancreas transplant recipients (226 simultaneous pancreas and kidney transplant (SPK), 101 pancreas transplant after kidney (PAK), and 97 pancreas transplants alone [PTA]) performed at a single center with at least 1-yr follow-up were reviewed. Immunosuppression included rabbit antithymocyte globulin induction, steroid withdrawal, and maintenance therapy of tacrolimus and sirolimus (± mycophenolate). In addition, PTA recipients received a single dose of rituximab. All recipients received valganciclovir prophylaxis. Donor (D)+/recipient (R)- recipients received 6 months of prophylaxis; all others received 3 months. The overall CMV infection rate was 12%. The cumulative incidences of CMV infection at 3, 6, 9, and 12 months after transplant were 0.25%, 3%, 7%, and 8%, respectively. CMV infection rates were 20.2% in the D+/R- group, 16.5% in the D+/R+ group, 5.0% in the D-/R+ group, and 2.8% in the D-/R- group. Infections were less common in SPK recipients. Most infections developed at least 3 months post-transplant, and 24% demonstrated tissue-invasive disease. Immunosuppression was NOT reduced in 72% of patients with infections. Ganciclovir-resistant CMV occurred in four patients. No patients died or lost their allografts due to CMV-related infection; one graft was lost due to chronic rejection associated with a reduction in immunosuppression. In many cases, CMV infections may be treated in pancreas transplant recipients without necessarily reducing immunosuppression.

Fever of Unkown Origin as a Sole Manifestation of Pancreas Allograft Rejection

Fever in a transplant recipient is almost always suspicious of an infectious etiology. We present a patient with simultaneous pancreas and kidney transplant who had persistent high grade fever for a month which could only be attributed to pancreas allograft rejection. A 56 year old white man with history of simultaneous kidney-pancreas transplant (SPK) a month prior presented with fever of unknown etiology. Patient denied any sick contacts or any localizing signs and symptoms. On examination, his temperature was 102.1 °F. Rest of the examination was unremarkable. His immunosuppression consisted of tacrolimus 3 mg twice daily, mycophenolate 1000 mg twice daily, and Prednisone 10 mg daily. Initial laboratory work up showed serum creatinine 1.8 mg/dl (Baseline serum Cr 1.8-2.0 mg/dl), tacrolimus level 14 ng/dl, serum amylase 82, serum lipase 67, glucose 89 mg/dl, and normal urine analysis. In addition, blood culture, urine culture, and serum cytomegalovirus, Epstein Barr virus and BK virus PCR were negative. Chest X ray and CT scan of abdomen and pelvis did not show any significant pathology. Patient's fever continued unabated in the range of 100-103°F daily for a month despite empirical antibiotic therapy while cultures remained negative. Rest of the negative work-up included an echocardiogram, kidney ultrasound with kidney biopsy, cerebrospinal fluid analysis, tagged white blood cell scan, upper and lower gastrointestinal scopes with biopsy of gastrointestinal mucosa for any viral inclusions. Nuclear PET scan showed increased activity in the pancreas transplant. Pancreas allograft biopsy confirmed pancreas allograft rejection although serum amylase and lipase were normal at the time of biopsy. Fever disappeared after initiation of steroids and has not recurred since discharge from the hospital 3 months ago. In conclusion, pancreas allograft rejection may present as fever of unknown etiology in a pancreas transplant recipient. Serum amylase and lipase may not be the reliable markers of pancreatic transplant rejection.

Optimizing pancreas transplantation outcomes in obese recipients.

Pancreas transplant recipient obesity has been associated with increased risk of perioperative complications, graft failure, and death. The imperative to maximize organ utility must be balanced against the need to maintain equity of access, including for the increasing number of obese diabetic patients. We compared the outcomes of pancreas transplant recipients with body mass index (BMI) greater than 30 kg/m(2) (n=60, mean ± SD BMI 32.1 ± 1.7 kg/m(2)) to those with BMI less than 30 kg/m(2) (n=308, mean ± SD BMI 24.5 ± 2.7 kg/m(2)) between 1996 and 2013. There were no differences in the pretransplant recipient or donor characteristics apart from BMI. The BMI greater than 30 group were more likely to suffer a rejection episode (43% vs. 29%; P = 0.03). The median time to first rejection was shorter (1 vs. 6 months; P = 0.04), and wound infection was more common in the BMI greater than 30 group (P = 0.03). There was no difference in the rate of patient, pancreas, or kidney graft survival or difference in graft function between the two groups. The obese recipients in this study were in the lower range of the obese category. Although there was an increased risk of rejection and wound infection in the obese group, there was no difference in patient or graft survival. This finding, when compared with previous reports, may be related to stringent recipient selection and posttransplant care particularly with respect to cardiovascular disease.

A Role for Transplant Endocrinologists - It's About Time

Since the introduction of clinical pancreas transplantation as a treatment for type 1 diabetes in the United States in the 1980s, endocrinologists, save the few conducting mechanistic investigations into the consequences of restoring endocrine function on metabolism and the complications of diabetes ( 1. Morel P. Goetz F.C. Moudry-Munns K. Freier E. Sutherland D.E. Long-term glucose control in patients with pancreatic transplants. Ann Intern Med. 1991; 115: 694-699 Crossref PubMed Scopus (66) Google Scholar ), have been largely uninvolved in the evaluation for or subsequent care and monitoring of pancreas transplant recipients. Historically, this may have been appropriate, since a pancreas transplant is usually added to a kidney transplant for a type 1 diabetic patient with end-stage nephropathy. Moreover, as kidney transplantation was established first, referral to a transplant center with medical determination for the indication of adding a pancreas and monitoring its function was handled by the transplant nephrologist. Finally, because the benefits of near-normal glycemic control in type 1 diabetes were not yet appreciated, success of a pancreas transplant was measured only by the postoperative insulin requirement, with a return to insulin therapy indicating graft failure.

Genetic Variation in Caveolin-1 Correlates With Long-Term Pancreas Transplant Function

Pancreas transplantation is a successful treatment for a selected group of people with type 1 diabetes. Continued insulin production can decrease over time and identifying predictors of long-term graft function is key to improving survival. The aim of this study was to screen subjects for variation in the Caveolin-1 gene (Cav1), previously shown to correlate with long-term kidney transplant function. We genotyped 435 pancreas transplant donors and 431 recipients who had undergone pancreas transplantation at the Oxford Transplant Centre, UK, for all known common variation in Cav1. Death-censored cumulative events were analyzed using Kaplan-Meier and Cox regression. Unlike kidney transplantation, the rs4730751 variant in our pancreas donors or transplant recipients did not correlate with long-term graft function (p = 0.331-0.905). Presence of rs3801995 TT genotype (p = 0.009) and rs9920 CC/CT genotype (p = 0.010) in our donors did however correlate with reduced long-term graft survival. Multivariate Cox regression (adjusted for donor and recipient transplant factors) confirmed the association of rs3801995 (p = 0.009, HR = 1.83;[95% CI = 1.16-2.89]) and rs9920 (p = 0.037, HR = 1.63; [95% CI = 1.03-2.73]) with long-term graft function. This is the first study to provide evidence that donor Cav1 genotype correlates with long-term pancreas graft function. Screening Cav1 in other datasets is required to confirm these pilot results.

Donor Risk Index Does Not Predict Graft Survival After Pancreas Transplantation in Brazil

BackgroundPancreas donor risk index (DRI) was developed by using large multicenter American data to predict the risk of adverse outcomes in pancreas transplantation based on donor and technical/logistical characteristics. AimThe goal of this study was to evaluate the usefulness of the DRI in predicting graft survival in a Brazilian population of pancreas transplant recipients. MethodWe conducted a retrospective analysis of the 570 procedures performed by the same surgical team between 1996 and 2011. Because of the lack of sufficient data for the calculation of DRI values, only 154 cases were studied (27%), of which 105 underwent simultaneous pancreas-kidney transplantation, 33 underwent pancreas after kidney transplantation, and 16 underwent pancreas transplantation alone. Donor cause of death was classified as cerebrovascular accident (CVA) and non-CVA. Graft origin was divided into three groups: local, if the graft was obtained in the metropolitan area of the city of São Paulo; regional, if collected in other cities of the state of São Paulo; and national, if obtained outside the state. ResultsLogistic regression analysis did not find a statistically significant association between DRI values and 1-year graft survival (odds ratio = 0.676; 95% confidence interval 0.152 to 3.014; P = .60). One-year graft survival calculated by the Kaplan-Meier method was 89.8% in transplants with DRI ≤ 1, 77.9% in those with 1 < DRI < 1.5, and 93.3% in those with DRI ≥ 1.5 (P = .106). ConclusionThe pancreas DRI model did not prove effective in predicting pancreas graft survival in a Brazilian sample of recipients.

Cooperative Study of the Spanish Pancreas Transplant Group (GETP): Surgical Complications

Technical failure in pancreas transplant has been the main cause of the loss of grafts. In the last few years, the number of complications has reduced, and therefore the proportion of this problem. ObjectivesThe Spanish Pancreas Transplant Group wanted to analyze the current situation with regard to surgical complications and their severity. Materials and methodsA retrospective and multicenter study was performed. 10 centers participated, with a total of 410 pancreas transplant recipients between January and December 2013. ResultsA total of 316 transplants were simultaneous with kidney, 66 after kidney, pancreas-only 10, 7 multivisceral and 11 retransplants. Surgical complication rates were 39% (n=161). A total of 7% vascular thrombosis, 13% bleeding, 6% the graft pancreatitis, 12% surgical infections and others to a lesser extent. Relaparotomy rate was 25%. The severity of complications were of type IIIb (13%), type II (12%), and type IVa (8.5%). Graft loss was 8%. Early mortality was 0.5%. The percentage of operations for late complications was 17%. ConclusionsThe number of surgical complications after transplantation is not negligible, affecting one in 3 patients. They are severe in one out of 5 and, in one of every 10 patients graft loss occurs. Therefore, there are still a significant percentage of surgical complications in this type of activity, as shown in our country.

The influence of socioeconomic deprivation on outcomes in pancreas transplantation.

Socioeconomic deprivation is an important factor in determining poor health and is associated with a higher prevalence of many chronic diseases including diabetes and renal failure, with poorer outcomes of their treatments. The influence of deprivation on outcomes following pancreas transplantation has not previously been reported. The Welsh Index of Multiple Deprivation was used to assess the influence of socioeconomic deprivation on outcomes for 119 consecutive pancreas transplant recipients from a single center in the United Kingdom, transplanted between 2004 and 2013. Outcomes measured were rate of acute rejection and graft survival. Thirty-five (29.4%) patients experienced at least one episode of acute rejection following their transplant. Rejection rates in least deprived were 37% and most deprived 24% (p = 0.29). Within the individual domains, rejection rate was higher for the "physical environment" domain (least deprived 40% vs. most deprived 17% (p = 0.053). Five-year graft survival for least and most deprived groups was 75% and 88%, respectively (log-rank test p-value 0.24). This study has not demonstrated any significant differences in outcomes following pancreas transplantation in Wales in relation to socioeconomic deprivation with the exception possibly of the "physical environment" domain. Further studies with larger patient population or concentrating on physical environment deprivation would be of interest.

Early postoperative continuous glucose monitoring in pancreas transplant recipients.

Continuous glucose monitoring (CGM) is used in people with type 1 diabetes to help with insulin treatment regimens. Its value in whole-organ pancreas transplantation (PT) is largely unknown. This study aimed to use CGM to assess the metabolic profile of pancreas transplant recipients in the early post-transplant period. We studied CGM data in 30 PT recipients and related findings to an early oral glucose tolerance test (OGTT). Complete data were available for 26 recipients. Seven days after a PT, normoglycaemia was present 77.9% of the time. Hypoglycaemic events (glucose <3.9 mmol/l) occurred in 10 of 26 (38.5%) of the cohort, but were infrequent (present 1.4% of the time). Hyperglycaemia (glucose >7.8 mmol/l) was present for 20.7% of the study period and correlated with a diagnosis of abnormal glucose tolerance. Whilst normoglycaemia is successfully achieved for the majority of the time after PT, hypoglycaemia can occur. Hyperglycaemia is more common and correlates well with the early postoperative OGTT, which is associated with graft failure. CGM is easier to perform and provides 24-h data that could inform clinical decision-making in patients in the postoperative period.

Estudio cooperativo del Grupo Español de Trasplante de Páncreas (GETP): complicaciones quirúrgicas

Technical failure in pancreas transplant has been the main cause of the loss of grafts. In the last few years, the number of complications has reduced, and therefore the proportion of this problem. ObjetivesThe Spanish Pancreas Transplant Group wanted to analyze the current situation with regard to surgical complications and their severity. Material and methodsA retrospective and multicenter study was performed. 10 centers participated, with a total of 410 pancreas transplant recipients between January and December 2013. ResultsA total of 316 transplants were simultaneous with kidney, 66 after kidney, pancreas-only 10, 7 multivisceral and 11 retrasplants. Surgical complication rates were 39% (n=161). A total of 7% vascular thrombosis, 13% bleeding, 6% the graft pancreatitis, 12% surgical infections and others to a lesser extent. Relaparotomy rate was 25%. The severity of complications were of type IIIb (13%), type II (12%) and type IVa (8.5%). Graft loss was 8%. Early mortality was 0.5%. The percentage of operations for late complications was 17%. ConclusionsThe number of surgical complications after transplantation is not negligible, affecting one in 3 patients. They are severe in one out of 5 and, in one of every 10 patients graft loss occurs. Therefore, there is still a significant percentage of surgical complications in this type of activity, as shown in our country.

Isoniazid treatment to prevent TB in kidney and pancreas transplant recipients based on an interferon-γ-releasing assay: an exploratory randomized controlled trial.

We performed a randomized trial of isoniazid treatment based on interferon-γ-releasing assay (IGRA) in kidney transplant (KT) recipients in an intermediate-TB-burden country. All adult patients admitted to a KT institute between June 2010 and May 2013 were enrolled. The IGRA (T-SPOT.TB assay) was performed on all patients, and isoniazid treatment was given to those with clinical risk factors for latent TB infection (LTBI). Patients with positive IGRA who had no clinical risk factors for LTBI were randomly assigned to isoniazid treatment or a control group. The development of TB after KT was monitored between June 2010 and November 2013. The primary endpoint was the development of TB. Of the 784 patients who had no clinical risk factors for LTBI, 445 (57%) gave negative results in the IGRA, 76 (10%) indeterminate results and 263 (33%) positive results. Of the latter, 131 were allocated to isoniazid treatment and 132 to the control group. Three (2%) of the control group developed TB, whereas none of the isoniazid treatment group developed TB (rate difference 1.22 per 100 person-years, P = 0.09). Of the 521 patients with negative or indeterminate IGRA results, 4 [0.8%, 0.43 per 100 person-years (95% CI 0.12-1.09)] developed TB after KT. IGRA-based isoniazid treatment has a trend towards reducing TB development in KT recipients without clinical risk factors, but careful monitoring of TB development is needed in negative-IGRA KT recipients.

Simultaneous pancreas and kidney transplantation: current trends and future directions.

Purpose of reviewImportant trends are being observed in pancreas transplantation in the USA. We will describe recent trends in simultaneous pancreas kidney (SPK) transplantation related to immunosuppression, treatment of rejection, and transplantation for patients of advanced age and C-peptide positive diabetes.Recent findingsRates of pancreas transplantation have declined, despite improved pancreatic graft outcomes. Regarding immunosuppression, trends in SPK transplantation include T-cell depletion induction therapy, waning mammalian target of rapamycin inhibitor use and steroid use in greater than 50% of pancreas transplant recipients with few patients undergoing late steroid weaning. Rejection of the pancreas may be discordant with the kidney after SPK and there is a greater appreciation of antibody-mediated rejection of the pancreas allograft. De-novo donor-specific antibody without graft dysfunction remains an active area of study, and the treatment for this condition is unclear. SPKs are being performed with greater frequency in type 2 diabetes mellitus patients and in patients of advanced age, with exemplary results.SummaryThe current state of the art in SPK transplantation is yielding superb and improving results.

Research Highlights

Sofosbuvir and Ribavirin Prevent Recurrence of Hepatitis C Virus Infection after Liver Transplantation: An Open-Label Study. Curry MP, Forns X, Chung RT, et al. Gastroenterology. 2014, September 24 Hepatitis C virus (HCV) is a leading cause of liver transplantation (LT), but due to recurrence of the virus in the graft, death and graft failure in this population remain higher than that in HCV-negative recipients.1 The ideal strategy to prevent recurrence of HCV after LT would be antiviral treatment with cure while on the LT waiting list. This study reports on the use of sofosbuvir and ribavirin treatment before LT to prevent HCV recurrence. Sixty-one patients with HCV and Child-Pugh of 7 or lower waiting for LT for hepatocellular carcinoma received up to 48 weeks of sofosbuvir (400 mg) and ribavirin before LT. Forty-six of 61 patients who received sofosbuvir and ribavirin were transplanted. Forty-three of 46 achieved HCV RNA load less than 25 IU/mL at the time of transplantation, thus qualifying for the study. Of these 43 patients, 30 (70%) were HCV-free at 12 weeks after LT. The only predictor of recurrent HCV was the duration of undetectable HCV RNA pre-LT: 24/25 of patients with 30 days or longer of undetectable HCV RNA pre-LT remained HCV-free after LT. Of the 13 patients who did not to achieve a response pre-LT, 10 had confirmed HCV recurrence and 3 died immediately after LT (2 from nonfunction of the primary graft and 1 from complications of hepatic artery thrombosis). The most frequently reported adverse events were fatigue (in 38% of patients), headache (23%), and anemia (21%). Those results are promising and with the recent approval of sobosbuvir, IFN-free treatment options are available for the benefit of these challenging patients. REFERENCE Berenguer M, Aguilera V, Rubin A, et al. Comparison of two noncontemporaneous HCV-liver transplant cohorts: strategies to improve the efficacy of antiviral therapy. J Hepatol 2012;56:1310. Persistent BK Viremia Does Not Increase Intermediate-Term Graft Loss but Is Associated With De Novo Donor-Specific Antibodies. Sawinski D, Forde KA, Trofe-Clark J, et al. J Am Soc Nephrol. 2014, September 25. There are only limited data regarding BK viremia and a potential augmentation of immune responses. BK infection frequently impairs graft function and had been associated with rejection. Moreover, rejection might be more prevalent because the standard treatment of BK infection includes a reduction of immunosuppressants. In addition, BK infections may also mediate allosensitization and rejection through heterologous immunity.1 Seven hundred eighty-five kidney or kidney–pancreas transplant recipients were included in this retrospective study that screened for BK viremia and DSA subsequent to transplantation. One hundred thirty-two of 785 (17%) recipients developed BK viremia during the study period; of note, older patients were more likely to become viremic, thus representing the only significant predictor of BK viremia in this study. A multivariate analysis did not find an association between development of BK and choice of induction or maintenance immunosuppression. However, patients were almost uniformly treated with ATG induction and tacrolimus-mycophenolate-based maintenance immunosuppression. No significant differences in serum creatinine levels between the viremic and nonviremic groups were detected by 3, 6, 12, 24, or 36 months after transplantation. Likewise, patient survival (97.0% in the BK+ group versus 97.2% in the uninfected group) and allograft survival (93.9% in the BK+ group versus 94.6% in the uninfected group) were not different between BK-infected and uninfected cohorts. There was a statistically significant increase in the risk of any de novo DSA (and class II in particular) in patients with persistent BK viremia. The data suggest that persistent BK viremia does not negatively affect intermediate-term patient or allograft survival, but is associated with increased risk for de novo DSA, although the exact mechanism is unclear. REFERENCE Aiello FB, Calabrese F, Rigotti P, et al. Acute rejection and graft survival in renal transplanted patients with viral diseases. Modern pathology: an official journal of the United States and Canadian Academy of Pathology, Inc. 2004;17(2):189.

Impact of recipient body mass index on short-term and long-term survival of pancreatic grafts.

The impact of recipient body mass index on graft and patient survival after pancreas transplantation is not well known. We have analyzed data from all pancreas transplant recipients reported in the Scientific Registry of Transplant Recipients between 1987 and 2011. Recipients were categorized into BMI classes, as defined by the World Health Organization. Short-term (90 days) and long-term (90 days to 5 years) patient and graft survivals were analyzed according to recipient BMI class using Kaplan-Meier estimates. Hazard ratios were estimated using Cox proportional hazard models. A total of 21,075 adult recipients were included in the analysis. Mean follow-up was 5 ± 1.1 years. Subjects were overweight or obese in 39%. Increasing recipient BMI was an independent predictor of pancreatic graft loss and patient death in the short term (P<0.001), especially for obese class II patient survival (hazard ratio, 2.07; P=0.009). In the long term, obesity, but not overweight, was associated with higher risk of graft failure (P=0.01). Underweight was associated with a higher risk of long-term death (P<0.001). These results question the safety of pancreas transplantation in obese patients and suggest that they may be directed to alternate therapies, such as behavioral modifications or bariatric surgery, before pancreas transplantation is considered.

Persistent BK viremia does not increase intermediate-term graft loss but is associated with de novo donor-specific antibodies.

There are limited data regarding intermediate-term outcomes in patients with persistent BK viremia. Other viral infections have been implicated in the development of allosensitization through heterologous immunity, but the relationship between BK viremia and donor-specific antibodies (DSAs) is unexplored. In 2008, we initiated routine post-transplant BK viremia and DSA screening at our center; 785 kidney or kidney-pancreas transplant recipients were included in our study. Of these recipients, 132 (17%) recipients developed BK viremia during the study period. The median duration of BK viremia was 140 days (interquartile range=40-393 days), and persistent BK viremia was defined as lasting ≥140 days. Kaplan-Meier curves were generated to assess differences in patient and allograft survival on the basis of BK viremia status; survival was modeled using Cox proportional hazard regression. After a median follow-up of 3 years, there was no significant difference in terms of patient (hazard ratio [HR], 0.83; 95% confidence interval [95% CI], 0.28 to 2.49) or allograft survival (HR, 0.80; 95% CI, 0.37 to 1.73) between patients with and without BK viremia, which was confirmed in a time-varying analysis. In our logistic regression model, persistent BK viremia was strongly associated with the development of class II (HR, 2.55; 95% CI, 1.30 to 4.98) but not class I (HR, 1.13; 95% CI, 0.46 to 2.77) DSAs. These data suggest that persistent BK viremia does not negatively affect intermediate-term patient or allograft survival but is associated with increased risk for de novo DSA, although the exact mechanism is unclear.

Successful Treatment of Acute Severe Graft-Versus-Host-Disease in a Pancreas-After-Kidney Transplant Recipient: Case Report

The development of acute graft-versus-host-disease (GVHD) in recipients of pancreas transplants is a rare and quite often a fatal post-transplantation complication. We present a 38-year-old male with a longstanding history of type 1 diabetes mellitus and end-stage kidney disease, with a living unrelated kidney transplant from his wife for 3 years, who received an enteric-drained 5-antigen HLA–mismatched deceased-donor pancreas. Five weeks after transplantation, he presented with spiking fevers, severe skin rash, diarrhea, pancytopenia, and increasingly abnormal liver function tests. Skin biopsies were consistent with grade 3 acute GVHD. The patient was treated for GVHD with escalated doses of tacrolimus, pulse doses of steroids, and basiliximab. He was discharged after a 4-week hospital stay with complete resolution of his rash, fever, abnormal liver enzymes, and leukopenia. He remained in good health with excellent kidney and pancreas allograft function 3 years later.

A survey of food safety information and foodborne infections post solid organ transplant

Summary Background & aims Over 4000 solid organ transplants are carried out annually in the United Kingdom and Republic of Ireland. These patients are commenced on essential immunosuppression therapy, which increases the likelihood of acquiring an infection from foods. Patients are given information to reduce this risk, however not all centres give this advice and the advice given is not standardised. This paper reports on the findings from a survey of dietitians that set out to describe current practice in relation to food safety information given post solid organ transplant. Methods An internet-based questionnaire was sent to transplant dietitians in the United Kingdom and Republic of Ireland enquiring about current practice and incidence of foodborne infections after a solid organ transplant. Results Thirty-eight questionnaires were returned containing information about heart, lung, kidney, liver, pancreas and small bowel transplant recipients. Respondents from all but one transplant centre reported they gave food safety advice. The recommended duration and content of the advice varied. The largest variable was regarding specific food avoidance. Foodborne infections were reported in patients following kidney, kidney-pancreas, liver and lung transplants. Conclusions There is variation in the food safety information given to patients after a solid organ transplant. Post transplant foodborne infection remains a serious complication of a solid organ transplant and its concurrent immunosuppression. Further development of knowledge in this area, would benefit patients who may already have compromised nutritional intake and health. Nationally standardised post transplant food safety information is recommended.

The Findings of For Cause Biopsies in Pancreas Transplant Recipients and Their Impact On Transplant Outcomes.

Background: There is limited data regarding the histological findings in pancreas allografts with graft dysfunction and the predictive value of the findings for the outcomes. We sought to determine the rate and type of acute rejection and the impact on graft survival. Methods: 132 pancreas transplant recipients required a total of 214 biopsies for graft dysfunction, in the form of elevation of amylase/lipase or hyperglycemia, between April 2003 and December 2012. Biopsies were evaluated for acute T-cell-mediated rejection (ACMR) and antibody-mediated rejection (AMR). Biopsies were scored according to the applicable criteria at the time of biopsy. The rejection episodes were treated with thymoglobulin in majority of the cases. Patient and graft survival rates were assessed. Results: Transplant type was categorized as simultaneous pancreas-kidney (SPK) in 63 patients, pancreas after kidney (PAK) in 42 patients, and pancreas transplant alone (PTA) in 27 patients. The mean recipient age was 40.2±8.1 years and 68 (51.5%) were male. The incidence of biopsies with ACMR, AMR, or both was 49.2%, 4.8%, and 1.6%, respectively. Patients were followed for 48.8±42.3 months until graft failure or censoring. The overall graft failure rate following the biopsy was 42.4%. Patients with rejection were not at an increased risk of graft loss compared to those free of rejection (HR=1.43, p=0.23). In this cohort recipients of SPK had a lower risk of graft loss compared to PTA (HR 0.38, p=0.005). In addition, the unadjusted risk of graft loss in men was 49% lower than women (p=0.021). During the follow up 9.1% of the patients died. Conclusions: Our data suggest that in pancreas transplant recipients with graft dysfunction, acute rejection is a dominant finding in the biopsies. However, with proper treatment the rejection does not have a significantly negative impact on graft survival.