Pancreas allograft rejection
- Tarek Alhamad, MD, MS, FACP, FASN
Tarek Alhamad, MD, MS, FACP, FASN
- Assistant Professor of Medicine
- Washington University School of Medicine
- Aleksandra Kukla, MD
Aleksandra Kukla, MD
- Associate Professor of Medicine
- University of Minnesota
- Robert J Stratta, MD
Robert J Stratta, MD
- Professor of Surgery, Director of Transplantation
- Wake Forest School of Medicine
- Section Editors
- Daniel C Brennan, MD, FACP
Daniel C Brennan, MD, FACP
- Editor-in-Chief — Nephrology
- Section Editor — Renal Transplantation
- Professor of Medicine
- Medical Director and Co-Director of the Comprehensive Transplant Center, Department of Internal Medicine, Division of Nephrology
- Johns Hopkins Medical School
- David M Nathan, MD
David M Nathan, MD
- Editor-in-Chief — Endocrinology
- Section Editor — Diabetes Mellitus
- Professor of Medicine
- Harvard Medical School
The outcomes of vascularized pancreas transplantation have steadily improved secondary to improvements in surgical techniques, donor and recipient selection and management, and diagnostic imaging, all of which have resulted in a reduction in early technical graft losses. In addition, advances in immunosuppression and immune monitoring have led to a commensurate decrease in immunological graft losses. However, pancreas allograft rejection remains a major clinical challenge and is the primary cause of death-censored pancreas allograft loss after three months posttransplant.
At present, approximately three-quarters of pancreas transplants in the United States are performed as simultaneous pancreas-kidney (SPK) transplants, with the remainder performed as either sequential pancreas after kidney transplant (PAK, 16 percent) or pancreas transplants alone (PTA, 9 percent) .
This topic reviews the epidemiology, clinical presentation, diagnosis, treatment, and prognosis of acute rejection of the pancreas allograft in the setting of SPK transplantation. However, this discussion is also applicable to pancreas allograft rejection in PAK and PTA recipients.
The selection of patients, induction, and maintenance immunosuppressive therapies are discussed elsewhere. (See "Patient selection for and immunologic issues relating to kidney-pancreas transplantation in diabetes mellitus".)
The benefits and complications (other than rejection) associated with these procedures and the roles of PTA and islet transplantation in diabetic patients without renal failure are discussed separately. (See "Benefits and complications associated with kidney-pancreas transplantation in diabetes mellitus" and "Pancreas and islet transplantation in diabetes mellitus".)
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- EPIDEMIOLOGY AND RISK FACTORS
- EVALUATION AND DIAGNOSIS
- Clinical manifestations
- Laboratory monitoring for allograft rejection
- Diagnosis of pancreas allograft rejection
- - When to suspect pancreas allograft rejection
- Approach to the diagnosis of pancreas allograft rejection
- - Patients with a PAK or PTA
- - Patients with a SPK transplant
- Confirming the diagnosis of pancreas allograft rejection
- - Acute cellular rejection
- - Antibody-mediated rejection
- - Mixed acute rejection
- Differential diagnosis
- Our approach to treatment
- Patients with biopsy-proven rejection
- - Patients with acute cellular rejection
- - Patients with antibody-mediated rejection
- - Patients with mixed acute rejection
- Patients with suspected (but not biopsy-proven) rejection
- Monitoring after treatment for rejection
- SUMMARY AND RECOMMENDATIONS