GVHD is rare after kidney-pancreas transplant with 18 case reports to date and never been described in the setting of PTA.We share our experience.

Patient A: 57 yr old Caucasian male, IDDM, hypoglycemic unawareness underwent PTA. Induction with rabbit ATG, with tacrolimus, rapamune and mycophenolate maintenance.7 months post-transplant patient developed tonsillar enlargement and was diagnosed with EBV + PTLD and underwent tonsillectomy and received anti-CD20 (rituximab). Mycophenolate was stopped and the target levels of tacrolimus and rapamune were lowered as well. Sixteen month post-transplant patient noticed a pruritic spreading rash. Based on biopsy diagnosis of Grade III GVHD was made. Dosage of tacrolimus and rapamune was increased along with initiation of prednisone. His pancreas allograft function started to deteriorate and biopsy showed chronic rejection. Eighteen month post-transplant a decision of allograft pancreatectomy was made as continuation of high dose immunosuppression in the view of recently treated PTLD and failed pancreatic allograft was determined to be more harmful than beneficial. Post allograft pancreatectomy, his GVHD responded well to low dose steroids, which were stopped 2 months later. Patient is more than 3 years out now.

Patient B: 54 yr old Caucasian male, with IDDM, underwent PTA, rabbit ATG induction with anti-CD20 maintained on tacrolimus/rapamune and mycophenolate mofetil. Three months post-transplant patient developed pruritic rash involving thighs and chest, based upon punch biopsies a diagnosis of grade II GVHD was made. DNA testing for T-cell chimerism confirmed the diagnosis. Patient was treated with steroids. Six months post-transplant patient developed another rash on his back and scalp, repeat biopsy was consistent with GVHD, he was on cyclosporine and rapamune for immunosuppression. Nine months post-transplant patient developed HHV-6 encephalitis and later a brain abscess and was started on antibiotics. 11 months post-transplant patient died from the complications of infection.

These patients never had immunosuppression exposure prior to PTA.

Conclusion:

GVHD although rare but should be considered in the differential diagnosis of a rash in PTA. Allograft pancreatectomy may be considered as an additional treatment option in a failed or failing allograft.

CITATION INFORMATION: Mujtaba M, Sharfuddin A, Khalil A, Taber T, Goble M, Powelson J, Fridell J. Graft Versus Host Disease (GVHD) in Patients with Pancreas Transplant Alone (PTA). Am J Transplant. 2016;16 (suppl 3).

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