Concurrent biopsies of both grafts in recipients of simultaneous pancreas and kidney demonstrate high rates of discordance for rejection as well as discordance in type of rejection - a retrospective study

Abstract

It is commonly assumed that in simultaneous pancreas and kidney (SPK) recipients, rejection of the two organs is concordant. As a result, concurrent biopsies of both organs are rarely performed and there are limited histological data on how often rejection is in fact discordant. We reviewed all SPK recipients transplanted at the University of Wisconsin between January 01, 2001, and December 31, 2016, that underwent biopsy of both organs. We included all patients whose biopsies were within 30 days. If patients were treated for rejection between biopsies, they were excluded if the biopsies were more than 4 days apart. Ninety-one simultaneous biopsies were performed within 30 days of each other, and 40 met our inclusion criteria. A total of 25 (62.5%) patients had concordance of biopsy findings: 11 had rejection of both organs, and 14 had no rejection of either organ. The other 15 (37.5%) were discordant for rejection, with 10 having pancreas-only rejection and five kidney-only rejection. It was striking to find that four of the 11 patients with concordance for rejection (36%) had different types (AMR, ACR, or mixed) of rejection in the two organs. This large series of simultaneous pancreas and kidney biopsies demonstrates the continued utility of performing biopsies of both organs.

Pancreas transplant rejection episodes are not revealed by biopsies of the donor duodenum in a prospective study with paired biopsies

“…[17][18][19] We found that normal duodenal graft biopsies had 96% specificity to suggest absence of rejection in the pancreas graft, but we do not recommend utilizing duodenal biopsies for ruling out rejection in the pancreas graft, since almost 60% (13/22) of our diagnosed pancreas graft rejections occurred together with normal duodenal findings. [17][18][19] We found that normal duodenal graft biopsies had 96% specificity to suggest absence of rejection in the pancreas graft, but we do not recommend utilizing duodenal biopsies for ruling out rejection in the pancreas graft, since almost 60% (13/22) of our diagnosed pancreas graft rejections occurred together with normal duodenal findings.…”

“…This observation is in line with what is found in SPK recipients in whom highly discordant findings are reported in concurrent biopsies from the kidney and pancreas graft, respectively. [17][18][19] We found that normal duodenal graft biopsies had 96% specificity to suggest absence of rejection in the pancreas graft, but we do not recommend utilizing duodenal biopsies for ruling out rejection in the pancreas graft, since almost 60% (13/22) of our diagnosed pancreas graft rejections occurred together with normal duodenal findings.…”

Renal Allograft Torsion Following Simultaneous Pancreas Kidney Transplant Should Be Suspected With Sustained Kidney Injury With Normal Pancreas Function

“…Moreover, a recent study by Parajuli et al demonstrated a 37.5% discordance rejection rate in simultaneous pancreas and kidney transplants, which prompted us to initially pursue rejection in the setting of normal pancreas function. 3 A high index of suspicion is required to differentiate renal rejection from renal allograft torsion as they can present similarly. In retrospect, we should have suspected graft torsion when the kidney was found to have moved medially on CT from its original position.…”

“…Moreover, a recent study by Parajuli et al demonstrated a 37.5% discordance rejection rate in simultaneous pancreas and kidney transplants, which prompted us to initially pursue rejection in the setting of normal pancreas function. 3…”

Discordant rejection in simultaneous pancreas and kidney transplantation: true discordance or analysis artefact?

“…The article by Parajuli et al . published in this issue of Transplant International is the latest, and perhaps the most convincing in a relatively small body of literature, to suggest that in a situation of simultaneous pancreas–kidney transplantation (SPK), in which both organs are from the same donor, one organ may be undergoing acute rejection independently from the other. The organ hierarchy in immunogenicity and susceptibility to rejection is a long‐known biological phenomenon, with the liver at one end of the spectrum and the intestine at the other.…”