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									HISTOPATHOLOGY OF
PANCREAS
TRANSPLANTATION

  Cinthia B. Drachenberg, M.D.
     University of Maryland
       School of Medicine
PANCREAS
TRANSPLANTATION
   19,000, October 2002 (IPTR)
PANCREAS
TRANSPLANTATION
PANCREAS
TRANSPLANTATION

   Graft survival rates continue to improve
       Simultaneous pancreas-kidney 85%
       Pancreas after kidney 77%
       Pancreas transplant alone 73%

       Patient survival at one year >94%
    HISTOPATHOLOGY
    OF PANCREAS TRANSPLANTATION

   12 years since the first percutaneous
    biopsies were performed (Allen et al.
    Transplantation 1991;51: 1213).




   1000 pancreas transplant bx at the
    Univ. of Maryland since 1992
Experimental models of acute
pancreas allograft rejection
   SEPTAL INFLAMMATION
       VENOUS ENDOTHELIITIS AND
        INFLAMMATION OF DUCTS
 ACINAR INFLAMMATION
 INFLAMMATION OF ARTERIAL
  BRANCHES
Allen et al: Am J Pathol 1991,138:303
Schulak et al: Surgery 1995,98:330.
Steineger et al: Am J Pathol 1986,124:253.
Carpenter et al: Transplantation 1989,48:764.
     GRADING ACUTE REJECTION
       0       No inflammation
       I       Minimal septal inflammation
       II      Venous endotheliitis
       III     Acinar inflammation
       IV      Arterial endotheliitis/
               transmural arteritis
       V       Parenchymal necrosis
(Drachenberg et al.: Transplantation 1997;63:1579-86)
       PANCREAS TRANSPLANT NEEDLE BIOPSY
   Minimum tissue amount adequate for
    diagnosis in a needle biopsy:
    Two lobules with associated septal tissue
     (arteries,veins, ducts).




   H&E stained sections x3
   Masson’s trichrome stain
   Unstained slides
Rates in graft loss due to rejection by era (IPTR)
      Comparison between the first 100
      and the last 100 biopsies
                         First 100   Last 100
Ac   Rej   Grade   0           15       29
Ac   Rej   Grade   I           9        8
Ac   Rej   Grade   II          12       8
Ac   Rej   Grade   III         44       28
Ac   Rej   Grade   IV          7        3
Ac   Rej   Grade   V           5        0

Total Acute Rej               68%       39%
March 2002




             April 2002




                          May 2002
      ACUTE AND CHRONIC REJECTION OVER TIME IN A
             TYPICAL CASE OF GRAFT LOSS


            5
REJECTION
 GRADES

            4
            3
            2                                          Acute Rej
            1                                          Chronic Rej
            0
                5    10      15   20   25   30
                          TIME IN MONTHS



                (Papadimitriou et al.: AJT May 2003)
       PANCREAS TRANSPLANTS: GRADING OF
       CHRONIC REJECTION/GRAFT SCLEROSIS




   Chronic rejection
    Grade 0
   Normal septa
       PANCREAS TRANSPLANTS: GRADING OF
       CHRONIC REJECTION/GRAFT SCLEROSIS


   Chronic rejection
    Grade I
   Fibrosis in <30%
    of core
   Center of the
    lobules intact
        PANCREAS TRANSPLANTS: GRADING OF
        CHRONIC REJECTION/GRAFT SCLEROSIS


   Chronic rejection
    Grade II
   Fibrosis in 30-60%
    of core
   Center of the lobules
    shows fibrosis
       PANCREAS TRANSPLANTS: GRADING OF
       CHRONIC REJECTION/GRAFT SCLEROSIS


   Chronic rejection
    Grade III
   Extensive fibrosis
    in >60% of core
   Minimal residual
    parenchyma
                      GRADO DE RECHAZO CRONICO EN RELACION AL TIEMPO
                       DESDE EL TRANSPLANTE Y EN RELACION AL TIEMPO
                             RESIDUAL DE FUNCION PANCREATICA


                             CHRONIC REJECTION GRADE IN RELATIONSHIP TO TIME ELAPSED
                                 POST-TX AND TIME OF REMAINING GRAFT FUNCTION


                 55

                 50

                 45

                 40
TIME IN MONTHS




                 35

                 30
                                                                                TIME P O S T- TX
                 25

                 20
                                                                                REMAINING TIME O F
                                                                                G RAFT FUNCTIO N
                 15

                 10

                 5

                 0
                         0             I               II            III
                                    CHRONIC REJECTION GRADE
    Comparison between the first 100
    and the last 100 biopsies
                    First 100   Last 100

Ch Rej Grade I           3         14
Ch Rej Grade II          1         5
Ch Rej Grade III         0         4

Total Chronic Rej        4%        23%
HISTOPATHOLOGY OF
PANCREAS TRANSPLANTATION
   In comparison to other solid organ
    transplants, less is known. This pathology
    field continues to evolve together with the
    clinical and surgical advances in pancreas
    transplantation.

   Has been a very important tool for the
    improvement of patient and graft outcomes,
    particularly in solitary pancreas
    transplantation.

								
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