Background: In the event of loss of function of a pancreatic graft, there are two safe options: suspension of immunosuppressive therapy followed by explantation of the grafted pancreas, or maintenance of reduced doses of mycophenolate without explanting the graft. Methods: A 73-year-old woman, who had received a pancreas transplant alone in 2001 when she was 54, since 2018 suffered the loss of renal function requiring hemodialysis treatment. In 2019, due to repeated acute rejection episodes, she has lost also the function of the grafted pancreas. First, tacrolimus therapy was suspended then, in March 2020 also mycophenolate was interrupted. In September 2020, the patient has accessed the emergency room for massive hematemesis. A contrast-enhanced computed tomography scan of the abdomen showed infected perigraft hematoma with an anastomotic pseudoaneurysm that fistulized in the graft duodenum. Results: The patient was immediately stabilized and underwent a radiological interventional procedure for stent placement in the native right common iliac artery, excluding the native right internal iliac artery and the anastomosis with the common branch of the Y artery graft for the transplanted pancreas. Two days later the patient underwent graft removal with ligation and section of the native right common iliac artery at the level of the anastomosis serving the transplanted pancreas. Due to acute ischemia of the right lower limb, 24 hours later a femoro-femoral arterial crossover was constructed using a cryo-preserved graft. Despite the full restoration of arterial vascularization to the ischemic limb, the patient died five days later. Conclusions: After the loss of a pancreatic graft, if not explanted, it is advisable to maintain immunosuppression at low doses to avoid recurrence of severe acute rejection phenomena with colliquative evolution of the transplanted organ, potentially leading to anastomotic pseudoaneurysms and/or fistulization in the grafted duodenum.

Effects of complete immunosuppression suspension after pancreatic graft loss

Fabio Vistoli;
2021-01-01

Abstract

Background: In the event of loss of function of a pancreatic graft, there are two safe options: suspension of immunosuppressive therapy followed by explantation of the grafted pancreas, or maintenance of reduced doses of mycophenolate without explanting the graft. Methods: A 73-year-old woman, who had received a pancreas transplant alone in 2001 when she was 54, since 2018 suffered the loss of renal function requiring hemodialysis treatment. In 2019, due to repeated acute rejection episodes, she has lost also the function of the grafted pancreas. First, tacrolimus therapy was suspended then, in March 2020 also mycophenolate was interrupted. In September 2020, the patient has accessed the emergency room for massive hematemesis. A contrast-enhanced computed tomography scan of the abdomen showed infected perigraft hematoma with an anastomotic pseudoaneurysm that fistulized in the graft duodenum. Results: The patient was immediately stabilized and underwent a radiological interventional procedure for stent placement in the native right common iliac artery, excluding the native right internal iliac artery and the anastomosis with the common branch of the Y artery graft for the transplanted pancreas. Two days later the patient underwent graft removal with ligation and section of the native right common iliac artery at the level of the anastomosis serving the transplanted pancreas. Due to acute ischemia of the right lower limb, 24 hours later a femoro-femoral arterial crossover was constructed using a cryo-preserved graft. Despite the full restoration of arterial vascularization to the ischemic limb, the patient died five days later. Conclusions: After the loss of a pancreatic graft, if not explanted, it is advisable to maintain immunosuppression at low doses to avoid recurrence of severe acute rejection phenomena with colliquative evolution of the transplanted organ, potentially leading to anastomotic pseudoaneurysms and/or fistulization in the grafted duodenum.
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Utilizza questo identificativo per citare o creare un link a questo documento: https://hdl.handle.net/11697/221164
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