Marcelo Perosa

Antibody-mediated rejection (AMR) after pancreas and pancreas-kidney transplantation.

Antibody‐mediated rejection (AMR) requires specific diagnostic tools and treatment and is associated with lower graft survival. We prospectively screened C4d in pancreas (n = 35, in 27 patients) and kidney (n = 33, in 21 patients) for cause biopsies. Serum amylase and lipase, amylasuria, fasting blood glucose (FBG) and 2‐h capillary glucose (CG) were also analysed. We found that 27.3% of kidney biopsies and 43% of pancreatic biopsies showed C4d staining (66.7% and 53.3% diffuse in peritubular and interacinar capillaries respectively). Isolated exocrine dysfunction was the main indication for pancreas biopsy (54.3%) and was followed by both exocrine and endocrine dysfunctions (37.1%) and isolated endocrine dysfunction (8.6%). Laboratorial parameters were comparable between T‐cell mediated rejection and AMR: amylase 151.5 vs. 149 U/l (P = 0.075), lipase 1120 vs. 1288.5 U/l (P = 0.83), amylasuria variation 46.5 vs. 61% (P = 0.97), FBG 69 vs. 97 mg/dl (P = 0.20) and 2‐h CG maximum 149.5 vs. 197.5 mg/dl (P = 0.49) respectively. Amylasuria values after treatment correlated with pancreas allograft loss (P = 0.015). These data suggest that C4d staining should be routinely investigated when pancreas allograft dysfunction is present because of its high detection rate in cases of rejection.

PERFORATION OF SIGMOID COLON AFTER EXTRACORPOREAL LITHOTRIPSY

A 32-year-old white man presented with an 8 mm. renoureteral calculus on the left side. He was placed in the ventral decubitus position and underwent ESWL with 3,000, 7 kV. shock waves. The patient had symptoms of nephritic colic on the left side and on day 5 after ESWL he complained of indistinct pain in the left iliac fossa along with 6 episodes of diarrhea in 24 hours. Symptoms improved after receiving analgesics but on day 7 significant clinical worsening was characterized by signs of septicemia and an acute abdomen. An x-ray of the abdomen revealed pneumoperitoneum with the right diaphragmatic cupula and bilateral disappearance of the psoas muscle line (fig. 1). With the diagnostic hypothesis of perforative acute abdomen due to the use of antiinflammatory drugs the patient underwent laparotomy. The surgical finding was diffise pustular peritonitis and a blocked 1 cm. perforation in the distal sigmoid colon in the mesocolic margin. No diverticulum or foreign body was identified in the colon or in the cavity. In the distal urethral projection an intense organized inflammatory process was identified. The patient elected resection of the perforated intestinal segment following terminal colostomy of the sigmoid, rectal stump closure, washing of the abdominal cavity and broad-spectrum antibiotic therapy (fig. 2). On pathological examination a perforative process was observed in a segment of the sigmoid with infiltrating polymor

Experience with 53 portal–duodenal drained solitary pancreas transplants

Systemic–enteric drainage is currently the most common technique for pancreas transplantation (PT). A novel alternative technique, portal–duodenal drainage (PDD), has potential physiological benefits and provides improved monitoring of the pancreatic graft. The current study describes 53 solitary PT procedures (43 pancreas after kidney and 10 pancreas transplant alone) using the PDD technique over the last three yr. This method resulted in one‐yr patient survival at 96% and 83% graft survival. There were five cases (9.4%) of thrombosis, in which transplantectomy and two‐layer closure of the native duodenum were performed. No fistulas were observed. Here, we demonstrate that the PDD technique in PT was as safe and effective as current techniques in clinical use.

Liver transplantation for neotropical polycystic echinococcosis caused by Echinococcus vogeli: a case report

Neotropical polycystic echinococcosis (NPE) is a parasitic disease caused by cestodes of Echinococcus vogeli. This parasite grows most commonly in the liver, where it produces multiples cysts that cause hepatic and vessel necrosis, infects the biliary ducts, and disseminates into the peritoneal cavity, spreading to other abdominal and thoracic organs. In cases of disseminated disease in the liver and involvement of biliary ducts or portal system, liver transplantation may be a favorable option. We present a report of the first case of liver transplantation for the treatment of advanced liver NPE caused by E. vogeli.

Over 500 pancreas transplants by a single team in São Paulo, Brazil.

Perosa M, Crescentini F, Noujaim H, Mota LT, Branez JR, Ianhez LE, Ferreira G, de Oliveira RA, Genzini T. Over 500 pancreas transplants by a single team in São Paulo, Brazil.
Clin Transplant 2011: 25: E422–E429.

Transplante de pâncreas isolado (órgão total) com drenagem vesical: relato do primeiro caso do Brasil

O transplante de pâncreas representa, no momento, a unica terapeutica capaz de determinar estado normoglicemico constante em pacientes com diabetes mellitus do tipo 1 (DM1), sendo indicado particularmente nas formas graves da doenca, geralmente traduzidas pelas complicacoes secundarias como a retinopatia, neuropatia e nefropatia. Sua indicacao mais consagrada e em associacao ao transplante renal para portadores de DM1 com insuficiencia renal, correspondendo a cerca de 85% dos transplantes de pâncreas no mundo. O transplante de pâncreas apos rim constitui outra indicacao aceita, uma vez que o paciente submetido previamente ao transplante renal ja se encontra sob o uso da imunossupressao. O transplante de pâncreas isolado permanece tema controverso, mas pode ser empregado em pacientes com DM instavel ou com complicacoes secundarias da doenca e funcao renal preservada. No presente artigo, relata-se o primeiro caso de transplante de pâncreas isolado empregando-se orgao total com drenagem vesical realizado no Brasil para o tratamento do DM instavel.

Donor‐derived malignancy in a pancreas graft

Donor-transmitted tumors may occur in about 0.02% of solid organ recipients [1]. Considering the rarity of these events, the case of a patient who developed malignancy in a pancreatic graft derived from a donor with a malignant glioma as the cause of brain death is reported. A 11-year-old white female child who had died from a malignant glioma was the organ donor. She had been diagnosed with malignant glioma by the age of 4 when a first craniotomy was performed and the tumor removed. Histological findings revealed a grade III pleomorphic xanthoastrocytoma. She was followed for 6 years asymptomatically up to the age of 10. By this time, she presented with seizures and headache episodes and a new surveillance showed recurrent cerebral tumor. Three consecutive craniotomies were performed within a period of 6 months for removal of the recurrent tumor. After the fourth craniotomy, she was evaluated for intracranial hypertension and progression to brain death. No ventriculo-peritoneal shunt, chemoor radiotherapy was performed during the follow-up. By the time of recovery of organs, no intra-abdominal or intra-thoracic abnormalities were noticed. Heart, liver, one kidney and pancreas were recovered for transplant in different recipients. One kidney was not used because of anatomical problems. Macroscopic appearance of the pancreas was normal. A pancreas transplant alone (PTA) was performed in a 21-year-old male patient, who had been diabetic for 19 years. The indication of the transplant was based on the presence of two secondary complications of the diabetes, including an advanced retinopathy and moderate nephropathy (proteinuria of 1.14 g/24 h and a creatinine clearance of 66 ml/min). Surgical technique consisted of bladder and systemic venous drainage with a total ischemia time of 6 h and 10 min. A quadruple sequential immunosuppression regimen was employed with thymoglobulin, mycophenolate mofetil, tacrolimus and prednisone. Early postoperative outcome was uneventful and the patient was discharged insulin-free 12 days post-transplant. No imaging study was performed until the 4th postoperative month according to our routine protocol for uncomplicated pancreas transplant recipients. By this time, the patient developed abdominal pain and an allograft pancreatic mass was diagnosed in an ultrasonography and confirmed by a CT scan. An ultrasoundguided biopsy was performed and revealed a malignant anaplastic tumor, compatible with glioma. A retrospective comparison between donorand recipient histological findings was carried out and this study confirmed the same malignant glioma in both patients, classified as a grade III pleomorphic xanthoastrocytoma by immunohistochemical staining. A graft pancreatectomy was performed and the surgical finding was a tumor limited to the head of the pancreas with no suspected infiltrative tissues or lymph nodes surrounding the graft (Fig. 1). Immunosuppression was promptly discontinued and the patient was restored to insulin. A strict follow-up has been done, with thoracic and abdominal CT scans performed every 6 months. His clinical evolution has been uneventful and the patient is stable and malignancy-free 5 years after graft removal.

Pancreas transplantation alone in children: a case report.

Abstract:  Pancreas transplantation (PT) is a relatively uncommon therapy for non‐uremic type 1 diabetes, as the severity of diabetes must warrant the risk of immunosuppression. In pediatric diabetic patients, who are less likely to display uremia because of the duration of diabetes, there is very little experience with pancreas transplantation alone (PTA). This report describes a 13‐yr‐old male PTA recipient. This patient was initially diagnosed with type 1 diabetes mellitus at the age of four yr. Following a multidisciplinary evaluation, PTA was found to be indicated based on a history of severe labile diabetes and hypoglycemic unawareness resulting in frequent episodes of hypoglycemia and hospital admissions. Because of the failure of medical management of the patient’s diabetes, a whole organ bladder and systemic drained PTA was performed. Immunosuppression included thymoglobulin, tacrolimus, mycophenolate mofetil, and steroids. Early outcome was uneventful and patient was discharged 12 d after surgery normoglycemic and insulin‐free. An episode of acute rejection (Maryland grade II) 20‐d post‐transplant was successfully treated with corticosteroids. A second and more severe episode of rejection (Maryland grade IV) occurred 13 months post‐transplant, requiring treatment with thymoglobulin and conversion from steroid to sirolimus. On tacrolimus, sirolimus, and mycophenolic acid, he remains euglycemic and insulin‐free 38 months after PTA. His quality‐of‐life is judged to be superior to his insulin dependent state prior to transplantation. According to the medical literature, this is the youngest patient ever to undergo PTA.

Insuficiência Hepática Aguda da Gravidez Experiência Clínica com Sete Casos

Purpose: to evaluate the diagnostic difficulties, treatment and outcome in cases of acute liver failure of pregnancy. Methods: seven patients with acute liver failure of pregnancy, managed during the past 4 years, were studied with emphasis on presenting symptoms, laboratory findings, clinical course, maternal complications and fetal outcome. Results: the mean age was 25.8 years (two were primigravidas), and the mean gestational age at onset was 30.1 weeks. The final diagnosis was acute fatty liver of pregnancy in four cases and intrahepatic cholestasis of pregnancy in three cases. Anorexia, nausea, abdominal pain, jaundice and encephalopathy were the main clinical findings. Two maternal deaths occurred: one due to hepatic failure, while waiting for transplantation, and another due to hepatic failure associated with coagulopathy and major intra-abdominal bleeding after liver biopsy. One patient with acute fatty liver of pregnancy underwent a successful liver transplantation one year ago (after chronification of her disease). The remaining four cases had complete resolution of the disorders after delivery and supportive measures. Maternal and fetal mortalities were 28.6% and 57.1%, respectively. Conclusion: from this initial experience, we conclude that acute liver failure of pregnancy is a serious disease, with high maternal-fetal mortality, and that early recognition of this illness, referral to tertiary liver centers, and prompt interruption of gestation are, together, very important for the success of the treatment.