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Protocol Duodenal Graft Biopsies Aid Pancreas Graft Surveillance

Gunther Brockmann, Jens, MD, PhD1; Butt, Amir2; AlHussaini, Hussa F.3; AlMana, Hadeel3; AlSaad, Khaled3; Al-Awwami, Moheeb4; Clemens Broering, Dieter1; Ali, Tariq5

doi: 10.1097/TP.0000000000002412
Original Clinical Science—General
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Background. Histological evaluation of the pancreas graft is usually done on demand resulting in significant delays. This analysis reports on endoscopic protocol duodenal graft biopsies at regular intervals to determine feasibility, safety, and monitoring benefits.

Methods. Protocol duodenal graft biopsies in 27 consecutive pancreas transplants (10 simultaneous pancreas kidney [SPK], 17 pancreas after kidney [PAK]) with a follow-up of a minimum of 12 months were performed at days 14, 30, 90, 180, 360, 430. University of Pittsburgh Medical Center classification for intestinal rejection was used. C4d staining was performed when antibody-mediated rejection was suspected.

Results. Overall patient and pancreas graft survival was 100% and 93% at a mean follow-up of 2.8 years. One hundred sixty-seven endoscopic biopsy procedures were performed in 27 grafts without any complication. Biopsies revealed rejection in 3 (30%) SPK recipients and in 15 (82%) of PAK recipients as early as 14 days posttransplant. Two patients underwent PAK retransplantation diagnosed with acute rejection at day 180. All except 1 recipient being treated for rejection, showed histological improvement following antirejection treatment. Following transient treatment success, a total of 3 pancreas grafts were lost for immunological reason. One loss was immediate despite antirejection treatment, 1 secondary to nonresolving rejection at 7 months and the third due to recurrent rejection 15 months posttransplantation. Additionally, biopsies detected vascular (venous thrombosis) and overimmunosuppression (cytomegalovirus infection) complications.

Conclusions. Protocol graft duodenal biopsies detect complications after whole-organ pancreas transplantation, are useful in guiding therapy, and carry potential for improving outcome.

1Department of Surgery, Organ Transplant Center, Riyadh, Kingdom of Saudi Arabia.

2Department of Intestinal and Pancreas Transplantation, Organ Transplant Center, Riyadh, Kingdom of Saudi Arabia.

3Department of Laboratory Medicine, Pathology, Riyadh, Kingdom of Saudi Arabia.

4Department of Laboratory Medicine, Histocompatibility Laboratory, Riyadh, Kingdom of Saudi Arabia.

5Department of Kidney & Pancreas Transplant Nephrology, Organ Transplant Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Kingdom of Saudi Arabia.

Received 20 March 2018. Revision received 10 July 2018.

Accepted 25 July 2018.

The authors declare no funding or conflicts of interest.

J.G.B. designed the research, wrote the article, performed surgery and follow-up, and participated in the data analysis. A.B. participated in research design, the writing of the article, the performance of the research (endoscopies), and participated in data analysis. H.A.H. participated in the writing of the article, the performance of the research (histology) and participated in data analysis. H.A.M. participated in the writing of the article, the performance of the research (histology) and participated in data analysis. K.A.S. participated in the writing of the article, the performance of the research (histology), and participated in data analysis. M.A. participated in the performance of the research (HLA analysis, follow-up). D.C.B. participated in research design. T.A. participated in the writing of the article, the performance of the research (follow-up), and participated in data analysis.

Correspondence: Jens Gunther Brockmann, MD, PhD, Section Head Kidney and Pancreas Transplantation, Department of Surgery and Organ Transplant Centre, King Faisal Specialist Hospital & Research Centre, P.O. Box 33554, Riyadh, 11211, MBC 37, Kingdom of Saudi Arabia. (brockmannjgb@me.com).

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