Pancreatic graft arterial thrombosis after coronary artery catheterization - an unusual case of pancreas allograft rejection
Ana Maia Silva, La Salete Martins, Leonídio Dias, António Castro Henriques, Anabela Giestas, Sofia Teixeira, Filomena Oliveira, Paulo Almeida, Rui Machado, Claudia Freitas, Rui Almeida, Manuel Teixeira & Jorge Dores
Introduction: Successful whole pancreas transplantation is at the present the most effective treatment for type 1 diabetes but allograft dysfunction related with infection, vascular compromise or immunological causes are not uncommon. Usually, graft vascular thrombosis or haemorrhage, as well as infectious complications are responsible for early pancreas graft failure; late cases occur more frequently by immunological causes, either allograft rejection or recurrence of the auto-immunity state that is characteristic of type 1 Diabetes.
Objective: To discuss a case of pancreas graft loss with coexistent graft arterial thrombosis and newly elevated anti-GAD antibodies.
Case report: A 43-year-old type 1 diabetic woman with end-stage renal disease and ischemic heart disease underwent a successful pancreas-kidney transplant and became free of insulin and dialysis for 5 years. Several days after coronariography there was a sudden appearance of hyperglycaemia (879 mg/dl), dehydration-related elevated serum creatinine (1.43 mg/dl), low C-peptide (0.37 ng/ml), normal serum amylase and lipase and newly elevated anti-GAD antibodies (120 U/ml). Vascular study was undertaken due to athero-embolization suspicion; angiography showed distal graft artery occlusion (donors superior mesentery artery). No graft biopsy was made. Alteplase treatment was performed during the angiography and the patient was treated with metilprednisolone bolus but unfortunately there was no radiological or clinical improvement and insulin-dependence remained.
Discussion: In the present case, graft loss seemed to occur due to arterial embolization after coronary catheterization. The rising of anti-GAD antibodies levels probably occurred due to antigenic expression because of the graft ischemia and not due to type 1 diabetes recurrence, but this complexity makes it very important to have a multidisciplinary team approach in the follow-up of these patients.