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Pancreas

Miscellaneous

Pancreas transplantation


Reviewer: Deepali Jain, M.D. (see Reviewers page)
Revised: 23 November 2012, last major update August 2012
Copyright: (c) 2001-2012, PathologyOutlines.com, Inc.

Whole organ transplant
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● Includes pancreas transplant alone, simultaneous pancreas and kidney transplant, pancreas after kidney transplant
● Pancreas and kidney transplanted together to achieve better glycemic control, and due to significant diabetic nephropathy
● Indications of whole organ transplant: chronic pancreatitis

Islet transplant
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● Main indication is severe type I diabetes; also patients for whom exogenous insulin may precipitate catastrophic hypoglycemia

Clinical features
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Early complications: graft pancreatitis, pancreatic thrombosis, endothelialitis of capillaries and venules
Late complications: recurrence of original disease, rejection (vasculitis, obliterative endarteritis, periductal lymphocytic infiltrate), mononuclear inflammation which preferentially destroys beta cells
● Survival: 95% at one year post-transplant, 83% after 5 years (Rev Diabet Stud 2011;8:6)
Poor prognostic factors: moderate to severe acinar inflammation, acinar tissue loss, fibrosis, vascular luminal narrowing (Am J Surg Pathol 1992;16:1098)
Note: transplanted islets produce more glucagon than insulin

Rejection
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● Adequate biopsy requires 3 lobular areas and associated interlobular septa
● Inflammation of acini, veins, arteries, ducts; associated with acinar cell damage
● Evaluation for arteritis is critical
● >75% mixed small and large T lymphocytes, fewer mature plasma cells, variable eosinophils
● <10% atypical cells

Acute rejection:
● Usually 7-12 months posttransplant
● Necrosis, infiltration of venous walls with associated endothelialiti
● Mild (Grade I): mononuclear septal inflammation with ductulitis and venulitis
● Moderate (Grade II): multiple foci (>3 foci per lobule) of acinar inflammation with associated single cell necrosis or drop out
● Severe (Grade III): Severe acinar inflammation, moderate-severe intimal arteritis
Banff schema: Am J Transplant 2008;8:1237, Am J Transplant 2011;11:1792 (updated for antibody mediated rejection)
Additional references: Adv Anat Pathol 2010;17:202, Arch Pathol Lab Med 2007;131:1192, University of Pittsburgh

● Chronic Rejection: acinar atrophy, aparenchymal fibrosis, obliterative arteriopathy
● Antibody-mediated rejection: C4d in vessels

Micro images
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Acute rejection


Chronic rejection


Various images

Banff criteria images

Differential diagnosis
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Posttransplantation lymphoproliferative disease: distinction important since opposite treatments; nodular and expansile infiltrates, mostly atypical, plasmacytoid B cells, occasional Reed-Sternberg-like cells; involves both acini and islets; extensive infiltration of peripancreatic soft tissues is common, no involvement of arterial walls unless concurrent acute vascular rejection; EBER+ (ISH) (Hum Pathol 1998;29:569)

End of Pancreas > Miscellaneous > Pancreas transplantation


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