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he was asymptomatic except for mild discomfort in the area of the pancreatic graft&#46; He was sent from the outpatient clinic for admission in order to obtain laboratory data related to pancreatic injury&#46;&#160;</p><p class="elsevierStylePara">&#160;His medical history included hypertension and type 1 DM with diabetic retinopathy and nephropathy&#59; he had received Continuous Ambulatory Peritoneal Dialysis &#40;CAPD&#41; for 18 months&#46; Ischaemic heart disease had been ruled out and he received pancreatic and kidney transplants 7&#46;5 years ago&#44; both of which are currently functional&#46;&#160;</p><p class="elsevierStylePara">&#160;The donor was a 21-year-old man who died of multiple trauma&#44; with the same blood group as the patient&#44; and no HLA compatibility among those that were tested&#46; The pancreas was transplanted with exocrine drainage into the duodenum&#46; Both grafts were initially functional&#44; the patient did not require insulin starting in the first 24 hours and plasma creatinine was 0&#46;8mg&#47;dl on the third day&#46; Thymoglobulin induction was performed during the first 4 days after transplantation&#44; and then suspended due to lymphopoenia and thrombocytopoenia&#46; Tacrolimus was started&#44; which&#44; along with MMF and prednisone&#44; became the patient&#8217;s maintenance immunosuppressive therapy&#46;&#160;</p><p class="elsevierStylePara">&#160;On the current admission the patient has good blood glucose control and blood pressure&#46; On physical examination&#44; the patient had no pathological findings except for discomfort on palpation of the epigastric area&#46; The main laboratory data obtained were&#58; plasma creatinine 1mg&#47;dl&#44; amylase 440mg&#47;dl&#44; lipase 403 U and tacrolimus levels of 3&#46;1ng&#47;ml&#46; Ultrasonography was performed which showed slight oedema of the pancreatic graft and resistive index &#40;RI&#41; within normal limits&#44; without abnormalities in the renal graft&#46;&#160;</p><p class="elsevierStylePara">&#160;The clinical symptoms were interpreted as being consistent with acute rejection of the pancreatic graft&#44; probably related to low levels of the anti-calcineurin agent&#46; In the first days after admission&#44; the tacrolimus levels were adjusted to 10ng&#47;ml and the patient was treated with 4 boluses of 6- methylprednisolone&#44; with reduction but not normalisation of pancreatic enzymes&#46; Treatment was initiated with thymoglobulin &#40;3mg&#47;kg&#41; via a jugular catheter&#46; This medication was poorly tolerated and the patient developed fever&#44; myalgias&#44; gastrointestinal intolerance&#44; and general worsening&#44; which improved with symptomatic treatment&#46; The pancreatic enzyme levels normalised after three doses of thymoglobulin&#44; and renal function remained stable&#46; Prophylactic treatment with septrim and oral valganciclovir was started at the time of discharge&#46;&#160;</p><p class="elsevierStylePara">&#160;Acute rejection is 1&#46;5 to 2 times more common in combined pancreas- kidney transplantation than in simple renal transplantation&#46; It also occurs later and is more often resistant to steroids&#46;<span class="elsevierStyleSup">3 </span>However&#44; graft loss due to a pancreatic rejection is more uncommon in the case of combined transplantation than in either of the other two methods &#40;pancreas after kidney and pancreas alone&#41;&#46;<span class="elsevierStyleSup">4 </span>Pancreatic rejection may or may not be associated with renal graft rejection and it can occur synchronously or asynchronously&#46; Confirmation by renal biopsy is sufficient when it occurs simultaneously&#46;&#160;</p><p class="elsevierStylePara">&#160;Pancreatic rejection initially occurs against acinar cells&#44; such that the islets of Langerhans continue functioning at first&#46; Thus&#44; uncontrolled blood glucose is a late event in the course of acute pancreatic rejection&#44; when more than 90&#37; of the graft has been affected&#46; In combined transplantation of the pancreas and kidney&#44; renal graft rejection is more common and more serious than pancreatic rejection&#44; and therefore monitoring of serum creatinine is usually used to detect rejection of both organs&#46; 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Acute rejection of pancreatic grafts
Rechazo agudo en el injerto pancreático
Ana Guitián Penaa, Ángel Alonso Hernándezb
a Servicio de Nefrología, Complejo Hospitalario Universitario de A Coruña, La Coruña, La Coruña, España,
b Servicio de Nefrología y Unidad de Trasplante Renal, Complejo Hospitalario Universitario de A Coruña, La Coruña, La Coruña, España,
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he was asymptomatic except for mild discomfort in the area of the pancreatic graft&#46; He was sent from the outpatient clinic for admission in order to obtain laboratory data related to pancreatic injury&#46;&#160;</p><p class="elsevierStylePara">&#160;His medical history included hypertension and type 1 DM with diabetic retinopathy and nephropathy&#59; he had received Continuous Ambulatory Peritoneal Dialysis &#40;CAPD&#41; for 18 months&#46; Ischaemic heart disease had been ruled out and he received pancreatic and kidney transplants 7&#46;5 years ago&#44; both of which are currently functional&#46;&#160;</p><p class="elsevierStylePara">&#160;The donor was a 21-year-old man who died of multiple trauma&#44; with the same blood group as the patient&#44; and no HLA compatibility among those that were tested&#46; The pancreas was transplanted with exocrine drainage into the duodenum&#46; Both grafts were initially functional&#44; the patient did not require insulin starting in the first 24 hours and plasma creatinine was 0&#46;8mg&#47;dl on the third day&#46; Thymoglobulin induction was performed during the first 4 days after transplantation&#44; and then suspended due to lymphopoenia and thrombocytopoenia&#46; Tacrolimus was started&#44; which&#44; along with MMF and prednisone&#44; became the patient&#8217;s maintenance immunosuppressive therapy&#46;&#160;</p><p class="elsevierStylePara">&#160;On the current admission the patient has good blood glucose control and blood pressure&#46; On physical examination&#44; the patient had no pathological findings except for discomfort on palpation of the epigastric area&#46; The main laboratory data obtained were&#58; plasma creatinine 1mg&#47;dl&#44; amylase 440mg&#47;dl&#44; lipase 403 U and tacrolimus levels of 3&#46;1ng&#47;ml&#46; Ultrasonography was performed which showed slight oedema of the pancreatic graft and resistive index &#40;RI&#41; within normal limits&#44; without abnormalities in the renal graft&#46;&#160;</p><p class="elsevierStylePara">&#160;The clinical symptoms were interpreted as being consistent with acute rejection of the pancreatic graft&#44; probably related to low levels of the anti-calcineurin agent&#46; In the first days after admission&#44; the tacrolimus levels were adjusted to 10ng&#47;ml and the patient was treated with 4 boluses of 6- methylprednisolone&#44; with reduction but not normalisation of pancreatic enzymes&#46; Treatment was initiated with thymoglobulin &#40;3mg&#47;kg&#41; via a jugular catheter&#46; This medication was poorly tolerated and the patient developed fever&#44; myalgias&#44; gastrointestinal intolerance&#44; and general worsening&#44; which improved with symptomatic treatment&#46; The pancreatic enzyme levels normalised after three doses of thymoglobulin&#44; and renal function remained stable&#46; Prophylactic treatment with septrim and oral valganciclovir was started at the time of discharge&#46;&#160;</p><p class="elsevierStylePara">&#160;Acute rejection is 1&#46;5 to 2 times more common in combined pancreas- kidney transplantation than in simple renal transplantation&#46; It also occurs later and is more often resistant to steroids&#46;<span class="elsevierStyleSup">3 </span>However&#44; graft loss due to a pancreatic rejection is more uncommon in the case of combined transplantation than in either of the other two methods &#40;pancreas after kidney and pancreas alone&#41;&#46;<span class="elsevierStyleSup">4 </span>Pancreatic rejection may or may not be associated with renal graft rejection and it can occur synchronously or asynchronously&#46; Confirmation by renal biopsy is sufficient when it occurs simultaneously&#46;&#160;</p><p class="elsevierStylePara">&#160;Pancreatic rejection initially occurs against acinar cells&#44; such that the islets of Langerhans continue functioning at first&#46; Thus&#44; uncontrolled blood glucose is a late event in the course of acute pancreatic rejection&#44; when more than 90&#37; of the graft has been affected&#46; In combined transplantation of the pancreas and kidney&#44; renal graft rejection is more common and more serious than pancreatic rejection&#44; and therefore monitoring of serum creatinine is usually used to detect rejection of both organs&#46; 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Article information
ISSN: 20132514
Original language: English
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