Acute Pancreatitis Transplant Rejection

Acute Pancreatic Transplant Rejection: Evaluation with Dynamic Contrast-enh...red with Histopathologic Analysis -- Krebs et al.
210 (2): 437 -- Radiology

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PubMed Citation
Articles by Krebs, T. L.
Articles by Bartlett, S. T.
(Radiology. 1999;210:437-442.)
RSNA, 1999
Gastrointestinal Imaging
Acute Pancreatic Transplant Rejection:
Evaluation with Dynamic Contrast-
enhanced MR Imaging Compared with
Histopathologic Analysis
Thorsten L. Krebs, MD
1
, Barry Daly, MD
1
, Jade J. Wong-You-Cheong,
MD
1
, Kieran Carroll, MB
1
and Stephen T. Bartlett, MD
2

1
Departments of Diagnostic Radiology (T.L.K., B.D., J.J.W.Y.C., K.C.)
2
Surgery (S.T.B.), University of Maryland School of Medicine, 22 S Greene St, Baltimore,
MD 21201.
Abstract
TOP
Abstract
Introduction
MATERIALS AND METHODS
RESULTS
DISCUSSION
References

PURPOSE: To evaluate the use of dynamic contrast materialenhanced

gradient-
recalled-echo MR imaging for the diagnosis of acute

pancreatic transplant rejection,
as confirmed at histopathologic

analysis.

MATERIALS AND METHODS: Thirty MR imaging studies were performed

in 25
patients within 3 days of percutaneous biopsy or pancreatectomy.

The mean
percentage of parenchymal enhancement (MPPE) at dynamic

contrast-enhanced MR
imaging was calculated.

RESULTS: Biopsy findings were no evidence of rejection (n =

7 [23%]), mild rejection (n = 10 [33%]), moderate (n = 6
[20%])

and severe (n = 2 [7%]) acute rejection, and infarction (n =

5 [17%]). The corresponding MPPEs at 1 minute were
106%, 66%,

62%, 57%, and 3%, respectively. Overlap of cases in the normal

and rejection groups occurred; however,
using an MPPE cutoff

of 100% resulted in a sensitivity of 96%. An MPPE over 120%

was seen in the normal group only.
The MPPE was significantly

greater in the normal group than in the rejection or infarction

group (P < .05).

http://radiology.rsnajnls.org/cgi/content/full/210/2/437 (1 of 12) [2/2/2005 3:16:50 PM]
Go
Acute Pancreatic Transplant Rejection: Evaluation with Dynamic Contrast-enh...red with Histopathologic Analysis -- Krebs et al. 210 (2): 437 -- Radiology
CONCLUSION: Dynamic contrast-enhanced MR imaging is highly sensitive

for the detection of acute pancreatic
transplant rejection.

Because of overlap of cases in the normal and rejection groups,

percutaneous biopsy may be needed in
some cases. Pancreatic

allografts with infarction can be clearly identified.

Index terms: Magnetic resonance (MR), contrast enhancement, 77.121412, 77.12143 Magnetic resonance (MR), tissue
characterization, 77.121412, 77.12143 Pancreas, MR, 77.121412, 77.12143, 77.12144, 77.12146 Pancreas,
transplantation, 77.458
Introduction
TOP
Abstract
Introduction
RESULTS
DISCUSSION
References

Pancreatic transplantation is performed in selected patients

who have major
complications of type 1 diabetes mellitus. Advances

in surgical technique and
postoperative management have improved

graft survival; however, up to 60% of
pancreatic transplants

have rejection episodes (1). Early detection of acute rejection

is
required to institute antirejection therapy promptly and

avert graft loss. Clinical and
biochemical indicators of rejection

have proved to be relatively insensitive and
nonspecific in

determining acute rejection (2,3). Similarly, computed tomography

(CT) and ultrasonography (US) have been demonstrated to be unreliable

for the detection of acute rejection (46).

Spin-echo MR imaging and gadopentetate dimeglumineenhanced

MR imaging have been inconsistent in the evaluation of
pancreatic

transplant dysfunction (79). In these series, only a few

cases were correlated with histopathologic results; most
of

the acute rejection cases were diagnosed by using clinical or

biochemical evaluation. Few pancreatic biopsy procedures
were

performed in prior studies because of the perceived risk of

complications and the need for general anesthesia and open
biopsy

(10). Recent developments in percutaneous technique now enable

safe and consistent biopsy of pancreatic
transplants (5,1114)

and thereby enable standard-of-reference correlation with imaging

findings. We analyzed the
usefulness of dynamic contrast materialenhanced

MR imaging in the diagnosis of acute rejection by correlating

MR
imaging enhancement patterns with histopathologic findings

obtained at imaging-guided percutaneous core biopsy or
surgical

explantation.

TOP
Abstract
Introduction
RESULTS
DISCUSSION
References

Patient Population
A computerized database of patients who had undergone pancreatic

transplant MR
imaging during 37 months, for a total of 158 MR

imaging examinations, was created.
The results of 32 studies

were correlated with histopathologic findings within 3 days

of the MR imaging examination. Two MR imaging studies were eliminated

because
of severe physiologic motion artifact, technical problems,

or both; this resulted in a
final study group of 30 images obtained

in 25 patients (15 men, 10 women; mean age,
37 years; range

2861 years). Fifteen patients had simultaneously transplanted

pancreas and kidney allografts from the
same donor (simultaneous

pancreatic/kidney), and eight had unrelated donor pancreatic

implants after a previously
successful kidney transplant (pancreas

after kidney). Two patients had a pancreatic transplant alone.

Four studies were
performed within 2 weeks after transplantation,

with a mean time of study after surgery of 3.8 months (range,

5 days to 1.7
years). Patients were referred for MR imaging

because of abnormal laboratory assay results that suggested

allograft
dysfunction in 24 cases and abdominal pain in six

cases. No asymptomatic patients were studied.

The surgical technique used for transplantation in all cases

was intraperitoneal placement of a cadaveric whole-organ
allograft

and a portion of the duodenal C loop into the iliac fossa. Exocrine

secretions were drained by either creating a
pancreaticoduodenocystostomy

whereby the donor duodenum was connected to the superior aspect

of the recipient's
bladder ("bladder drained") or draining the

small intestine where the donor duodenum was anastomosed to

a loop of
recipient jejunum ("enteric drained"). All but four

studies (in three patients) involved bladder-drained allografts.

Histopathologic Correlation
Correlation was made with the results of imaging-guided percutaneous

pancreatic biopsy, which was performed in 24 cases
(22 US guided,

two CT guided) within 3 days after the MR imaging studies (mean,

1.4 days) by using a previously
described technique (5,1114).

Three patients underwent biopsy within 2 weeks after transplantation,

and most biopsy
procedures were performed within 4 months after

surgery (range, 10 days to 44.3 months; mean, 3.9 months). Indications

for percutaneous pancreatic biopsy were a twofold increase in

the serum amylase or lipase level, a sustained (ie, 40% or
greater)

decrease in the urinary amylase level, or clinical features

suggestive of acute rejection such as fever, graft
tenderness,

or abdominal distention.

Patients with biochemical abnormalities that improved after

urinary catheterization of bladder-drained allografts were
considered

to have reflux pancreatitis and thus did not undergo biopsy

and were not included in this series. The MR
imaging findings

were correlated with the results of analyses of pancreatic specimens

removed at surgery in six cases, with
a mean time from imaging

to surgery of 2.2 days. One patient underwent explantation within

a week after transplantation.
Most of the remainder of the explanted

allografts were older than 1 year (range, 5 days to 50.6 months;

mean, 18.3
months). Pancreatic explantation was performed because

of unremitting abdominal pain, severe hyperglycemia that
required

insulin, imaging findings suggestive of infarction, or all three

of these indications.

Biopsy results were evaluated by experienced histopathologists.

The severity of acute rejection, if present, was graded as
mild,

moderate, or severe by using a qualitative analysis system that

has been demonstrated to correlate with graft survival
(15).

This grading scale was based on the degree of vascular, septal,

and acinar inflammatory changes (15). In addition, the
presence

of infarction or vascular thrombosis was noted. Biopsy specimens

that did not have pancreatic parenchyma were
not included in

the study.

MR Imaging and Analysis
All MR imaging studies were acquired on a 1.5-T system (Signa,

GE Medical Systems, Milwaukee, Wis) with a phased-
array coil.

Initially, a fast multiplanar spoiled gradient-recalled-echo

(GRE) MR image in the sagittal plane (20/1.2 [TR
msec/TE msec],

60 flip angle, 256 x 128 matrix, two signals averaged,

10-mm section thickness without gap) was
obtained to determine

the area of coverage. Before and immediately after injection

of the contrast material, a coronal 23-
second, breath-hold T1-weighted

fast multiplanar spoiled GRE image (150/4.2, 60 flip angle,

256 x 128 matrix, 5-mm
section thickness without gap, 24-cm

field of view) was acquired, and imaging was repeated every

minute for 5 minutes.
Thirteen sections per breath hold were

obtained; this permitted coverage of the entire pancreatic allograft.

After written
informed consent was obtained, an intravenous

bolus injection (0.1 mmol per kilogram of body weight injected

for 510
seconds) of gadopentetate dimeglumine (Magnevist;

Berlex Laboratories, Wayne, NJ) followed by a saline flush was

administered through a 21-gauge needle. These two sequences

required approximately 15 minutes of imaging time. In
addition,

axial T2-weighted chemical fat-suppressed fast spin-echo MR

imaging and flow-sensitive MR angiography were
performed, but

these images were not evaluated for the purposes of this study.

During the unenhanced breath-hold study, a mean glandular signal

intensity for each pancreatic transplant was derived by
averaging

two 1-cm-diameter regions of interest from a representative

image section that encompassed the middle portion
of the tail

and head of the transplanted pancreas. The representative areas

were selected by one investigator (K.C.) without
knowledge of

the results of histopathologic analysis. Pancreatic allograft

enhancement may be heterogeneous, and focal
areas of signal

intensity abnormality (eg, intraparenchymal fluid collection)

were excluded from sampling. The same
regions of interest were

measured during the subsequent contrast enhancement portion

of the study. In most cases, a single
section was adequate for

analyzing both the head and tail of the transplanted pancreas.

These measurements were used to
calculate a mean percentage

of parenchymal enhancement (MPPE) for each breath-hold gadolinium-enhanced

GRE study
by using the following formula: MPPE = (contrast-enhanced

MGSI - unenhanced MGSI) x 100%/unenhanced MGSI,
where MGSI is

the mean glandular signal intensity. A time-enhancement curve

was created by using these values plotted
against the histopathologic

findings.

Statistical Analyses
An unpaired Student t test was performed with the MPPE measurements

during the 1-minute breath-hold (90 seconds after
the bolus

injection) portion of the gadolinium-enhanced MR imaging study,

which was stratified by using histopathologic
subgroups and

Excel version 7 (Microsoft, Redmond, Wash). A statistically

significant difference in means was considered
to be present

when P was less than .05. Sensitivity, specificity, and accuracy

were calculated with standardized formulas.

RESULTS
TOP
Abstract
Introduction
RESULTS
DISCUSSION
References

Acute graft rejection was diagnosed in 18 (75%) percutaneous

biopsy specimens, 10
of which were graded as mild; six, moderate;

and two, severe. In seven (23%) biopsy
specimens, there was

no evidence of glandular rejection. Five of six explanted
allografts

showed histopathologic evidence of severe infarction. In four

of five cases,
underlying severe acute rejection was also detected;

the one case without acute
rejection occurred within a week

of transplantation and demonstrated vascular
thrombosis. One

of the six explanted allografts had severe acute rejection without

infarction. No biopsy specimens showed evidence of acute pancreatitis

or chronic rejection.

Comparison of the time-MR enhancement curves with the histopathologic

findings revealed three basic patterns (Fig 1).
The average

MPPE in the normal group was greater for each time measurement

than in all other histopathologic groups. A
peak mean enhancement

of 106% occurred at 1 minute, with a subsequent minimal decrease

over time. For each period, the
average MPPE in the rejection

subgroups was similar between these groups; it remained well

below the average MPPE in
the normal group and never exceeded

67%. Enhancement in mild and moderate grades of rejection peaked

at 1 minute and
subsequently diminished. The MPPE in the severe

rejection group rose slightly over time. Transplanted organs

that
demonstrated infarction had an average MPPE that was well

below that in the rejection and normal subgroups and
remained

less than 6% for all periods.

View larger version (16K):
[in this window]
[in a new window]

Figure 1. Average of MPPEs measured over 5 minutes plotted according
to histopathologic diagnoses of normal, mild, moderate, and severe acute
rejection and of infarction.

The optimal period for data separation occurred at the 1-minute

breath-hold portion of the study (90 seconds after contrast

injection), where the greatest difference in MPPE occurred;

MPPE measurements were 106% in the normal group and
66%, 62%,

57%, and 3% in the transplanted organs with mild, moderate,

and severe grades of rejection and with infarction,
respectively

(Fig 2). The MPPE in the normal group was significantly greater

than that in the rejection subgroups (P < .05);
however,

there was an overlap of cases between these groups. Clear separation

of the normal group and group with
infarction (P < .01) was

present without overlap. Pairwise analyses revealed no significant

difference in MPPE between the
different grades of rejection

(P > .05), but there was significantly greater enhancement

on the images in the rejection group
than on those in the infarction

group, without overlap (P < .005).

[in this window]
[in a new window]

Figure 2. Scatter diagram shows the range of MPPEs at 1 minute with
histopathologic diagnoses of normal, mild, moderate, and severe acute
rejection and of infarction.

If an MPPE cutoff value of 100% were used to predict rejection,

a sensitivity, specificity, and accuracy of 96%, 67% and
87%,

respectively, would result. The one false-negative case demonstrated

mild acute rejection at histopathologic analysis
and had an

MPPE of 116% at MR imaging. Two of the three false-positive

cases were in the normal group; the other was a
case of infarction

without rejection. If an MPPE cutoff of 20% were used to evaluate

for transplant infarction, the resultant
sensitivity and specificity

each would be 100%.

DISCUSSION
TOP
Abstract
Introduction
RESULTS
DISCUSSION
References

Several MR imaging techniques have been evaluated for the noninvasive

determination of acute pancreatic transplant rejection. Prior

studies (79,16,17) in
which the use of unenhanced MR imaging

for assessment of pancreatic rejection was
evaluated have had

variable results and limited histopathologic correlation. Yuh

et al
(16) found spin-echo MR imaging to be 100% sensitive and

76% specific for acute
pancreatic graft rejection in a series

of 44 studies, as determined by using clinical
assessment only.

The allograft edema that occurs with acute rejection was
qualitatively

identified when the glandular signal intensity was either less

than the signal intensity of muscle on T1-
weighted images or

greater than or equal to the signal intensity of the bladder

urine on T2-weighted images. Vahey et al
(17) quantitatively

evaluated pancreatic transplant signal intensity on 13 MR imaging

studies in nine patients. They found
that the mean calculated

T2 of the seven transplants with rejection was substantially

elevated compared with that of the
allografts without rejection.

However, seven studiesfive with pancreatic tissue and

two with renal tissuehad histologic
correlation. In comparison,

by using clinical assessment, Kelcz et al (8) and Fernandez

et al (9) evaluated the quantitative
measurement of pancreatic

transplant signal intensity with spin-echo sequences and were

not able to demonstrate signal
intensity differences in pancreatic

allograft dysfunction.

Experience with contrast-enhanced MR imaging for assessment

of pancreatic allograft rejection has been limited.
Fernandez

et al (9) obtained dynamic, single-section contrast-enhanced

MR images through the pancreatic transplant
during breath holding.

They demonstrated that the percentage of enhancement in normally

functioning pancreatic
transplants was greater than that in

dysfunctional allografts (with either rejection or infarction).

In six cases of normally
functioning allografts, they recorded

a mean percentage of enhancement at 1 minute of 98% compared

with 42% in six
cases with acute dysfunction. In their series,

the findings of five MR imaging studies were correlated with

pancreatic
transplant biopsy results.

Although many transplantation centers now use percutaneous pancreatic

transplant biopsy to reliably diagnose acute
rejection (11,13,18),

this previously was not the case. Acute pancreatic rejection

was thought to occur synchronously with
acute renal rejection

in simultaneously transplanted pancreas and kidney allografts

from the same donor, and pancreatic
rejection was not thought

to occur in isolation (19). Because renal rejection could easily

be diagnosed by using serum
creatinine levels and percutaneous

renal biopsy, the accepted practice was to use renal rejection

to determine pancreatic
rejection (1922). However, it

has been demonstrated that episodes of acute rejection after

simultaneous renal and
pancreatic transplantation may be discordantthat

is, may occur in one organ but not in the otherin 22%47%

of cases
(23,24). A sensitive noninvasive imaging study would

be preferable because it would enable the small but substantial

(ie,
up to 3%) risk of major complications after percutaneous

pancreatic biopsy to be avoided (5,14).

In our study, we compared the results of dynamic breath-hold

contrast-enhanced pancreatic allograft MR imaging with
those

of standard-of-reference histopathologic analysis. Normally

functioning transplanted organs tended to enhance avidly
with

contrast material administration, whereas the transplanted organs

with rejection enhanced less actively. At 1 minute,
the percentage

of enhancement in the normal group was substantially greater,

106%, compared with 50% in the
dysfunctional group (ie, transplants

with rejection and infarction); these results are similar to

those of the study by
Fernandez et al (9). However, in their

study, dysfunctional transplanted organs were not separated

into rejection versus
infarction groups, presumably because

of the limited number of cases. In our study, the MPPE in the

transplanted organs
with rejection at 1 minute (63%) was markedly

different from that in the transplanted organs with infarction

(3%).

One of the mechanisms of dysfunction that occurs with acute

pancreatic rejection is an alloimmune vasculitis (25).
Decreased

contrast enhancement in the transplanted organ, as occurred

in the allografts with acute rejection in our study,
may be

due to narrowed or occluded small vessels, which result in a

decreased rate and degree of accumulation of
extracellular contrast

material. For this purpose, gadolinium-based extracellular contrast

materials for MR imaging have an
advantage over the iodinated

contrast materials that are used for CT, because most recipients

have a coexistent renal
transplant, and there is a reduced risk

of nephrotoxicity.

The difference in enhancement between normal transplanted organs

and dysfunctional allografts on gadolinium-enhanced
GRE MR images

may be useful in the clinical assessment and treatment of allograft

recipients and in helping to guide the
selective use of biopsy.

In our study, despite the overlap of MPPE data points in the

normal and rejection groups, the
MPPE in the normal group was

significantly different from that in the rejection group (P

< .05). Gadolinium-enhanced
GRE MR imaging appears to be

highly sensitive for the detection of rejection; an MPPE cutoff

of 100% resulted in a
sensitivity of 96% (Figs 3, 4). In our

series, the one false-negative case was due to infarction in

a transplanted organ
without acute rejection. Failure to diagnose

this case by using MR imaging was not clinically relevant, because

the allograft
needed to be removed regardless of whether acute

rejection was present. The two histopathologically normal false-positive

cases, which occurred in transplanted organs that had diminished

enhancement, were more problematic. If MR imaging had
been used

as the sole guide for antirejection treatment instead of biopsy,

unnecessary therapy may have been instituted.
These allografts

may have had areas of acute rejection that were not detected

because of biopsy sampling error. An MPPE
of greater than 120%

was demonstrated in normally functioning allografts only; this

indicates that this group may not
require biopsy. There was

a very small number of such cases in our series. The converse

may also be useful; allografts with
an MPPE of less than 60%

were dysfunctional owing to either acute rejection or infarction.

[in this window]
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Figure 3a. Coronal fast multiplanar spoiled GRE MR images (150/4.2, 60
flip angle) obtained in a patient with a normal pancreas allograft, as
confirmed at percutaneous biopsy. (a) Unenhanced image and (b) image
obtained 1 minute after the administration of gadolinium-based contrast
material demonstrate avid enhancement throughout a normal-sized
pancreatic allograft (straight arrows). Note the adjacent enteric anastomosis
(curved arrow) and renal allograft (arrowheads). The measured MPPE was
122%.

[in this window]
[in a new window]

Figure 3b. Coronal fast multiplanar spoiled GRE MR images (150/4.2, 60
flip angle) obtained in a patient with a normal pancreas allograft, as
confirmed at percutaneous biopsy. (a) Unenhanced image and (b) image
obtained 1 minute after the administration of gadolinium-based contrast
material demonstrate avid enhancement throughout a normal-sized
pancreatic allograft (straight arrows). Note the adjacent enteric
anastomosis (curved arrow) and renal allograft (arrowheads). The
measured MPPE was 122%.

[in this window]
[in a new window]
Figure 4. Coronal fast multiplanar spoiled GRE MR image (150/4.2, 60
flip angle) obtained 1 minute after the administration of gadolinium-based
contrast material in a patient with moderate acute rejection of pancreatic
allograft, as confirmed at percutaneous biopsy. Image demonstrates
diminished enhancement (straight arrows) compared with the
enhancement in the pancreas in Figure 3b. Mild hydronephrosis of the
renal transplant (curved arrow) is noted. The measured MPPE was 72%.

Another reason to develop a clinically useful imaging technique

for the diagnosis of acute rejection in pancreatic allografts

is that pancreatic allografts are no longer routinely placed

in the pelvis (26). Instead, the pancreatic allograft is placed

in the
mesentery of the middle part of the abdomen, with portal

venous drainage of endocrine secretions. Portal venousdrained

pancreatic transplants have the theoretic advantage of normalized

insulin physiology (26). Unfortunately, these
transplanted organs

are more difficult to monitor with imaging because they are

often located deeply within the abdomen
and may have surrounding

interposed bowel; therefore, they are also more difficult to

perform biopsy on percutaneously.
Hence, a sensitive, noninvasive

alternative for predicting rejection episodes has greater importance.

Graft thrombosis that leads to allograft infarction is another

major cause of graft loss. This event can occur early (ie, in

less
than 1 month) or late after surgery. Early graft thrombosis,

as occurred in one patient in this series, is usually the result

of
vascular graft anastomotic error or microvascular damage

from preservation injury. Late thrombosis (ie, that which occurs

more than a month after surgery), as occurred in four cases

in this series, usually results from severe acute rejection

with
alloimmune arteritis and causes occlusion of small vessels,

which leads to complete major vessel occlusion. Regardless of

the causes, all cases with an MPPE of less than 10% in our study

had infarction and were identified by using gadolinium-
enhanced

GRE MR imaging (Fig 5). Identification of total graft thrombosis

and infarction is important, because the
transplanted organ

should be removed immediately to avoid the severe systemic effects

of graft autolysis (21). Acute
rejection, regardless of its

severity, is usually treated medically, and the allograft usually

does not need to be removed;
however, it may be difficult to

differentiate severe rejection from graft infarction in the

clinical setting. In our study, there
was no overlap of cases

between the rejection subgroups and the infarction group. Therefore,

the described technique
appears to be useful in separating these

two diagnoses. This supports the findings in previous MR imaging

literature (27),
which have demonstrated a lack of enhancement

in pancreatic allografts with infarction in a small number of

cases.

[in this window]
[in a new window]

Figure 5. Coronal fast multiplanar spoiled GRE MR image (150/4.2, 60
flip angle) obtained 1 minute after the administration of gadolinium-based
contrast material in a patient with pancreatic allograft infarction that was
proved at surgical explantation. There is no enhancement in the enlarged
pancreatic allograft (white arrows) or in the duodenal cuff (black arrow).
The measured MPPE was 1%. A normal enhancing renal transplant
(arrowheads) is noted.

Limitations of this study include a relatively small patient

population. At our institution, MR imaging is used for
problematic

cases that could not be adequately assessed by using US or CT.

The study group was further diminished
because of our requirement

that a maximum of 3 days intervene between the histopathologic

and MR imaging
examinations (mean interval, 1.4 days). Increasing

this interval would have increased the number of cases in the

series, but
it would have diminished the quality of the histopathologic

correlation. A further limitation of our study is that
percutaneous

biopsy was performed on only one site in the pancreas allograft.

We could have potentially underdiagnosed
the prevalence of acute

rejection. In addition, because the study was performed retrospectively,

the use of the described
modality should be evaluated further

in a prospective manner.

In summary, we correlated dynamic contrast-enhanced GRE MR imaging

findings in pancreas allografts with
histopathologic results,

as determined by using pancreatic biopsy specimens, and found

significant differences in the
enhancement patterns. The mean

percentage of enhancement in normal pancreatic transplants on

dynamic MR imaging
studies at 1 minute was 104%, which was significantly

greater than the 67% and 3% in the pancreatic transplants that

had
acute rejection and infarction, respectively. Transplanted

organs with infarction can be clearly differentiated from viable

allografts for prompt surgical intervention. Despite the overlap

of acute rejection and normal cases, decreased enhancement
on

MR images appears to be highly sensitive for rejection. Such

imaging findings in the appropriate clinical setting and/or

with associated biochemical abnormalities may allow greater

confidence in clinical decision making. By using an MPPE
cutoff

of 100%, gadolinium-enhanced GRE MR imaging was 96% sensitive

for the detection of acute rejection. Biopsy
may not be required

in transplanted organs with an MPPE of greater than 120%. For

clinically indeterminate cases, in
particular those with an

MPPE of 100%120%, biopsy may be required. Sensitive detection

of acute rejection is likely to
be important in portal venousdrained

pancreatic transplants, in which percutaneous biopsy cannot

be readily performed.

Acknowledgments

We thank Jeffrey M. Silverman, MD, for his helpful comments.

In addition, we thank Linda Clarke for manuscript
preparation

and David Crandall for photographic assistance.

Footnotes

Address reprint requests to T.L.K.

From the 1997 RSNA scientific assembly.

Abbreviations: GRE = gradient-recalled echo MPPE = mean percentage

of parenchymal enhancement

Author contributions: Guarantor of integrity of entire study,

T.L.K.; study concepts and design, T.L.K., B.D., J.J.W.Y.C.;

definition of intellectual content, T.L.K., B.D., J.J.W.Y.C.;

literature research, T.L.K.; clinical studies, T.L.K., B.D.,

J.J.W.Y.C., K.C., S.T.B.; data acquisition, K.C.; data analysis,

T.L.K., B.D., J.J.W.Y.C., K.C.; statistical analysis, T.L.K.,

B.D., J.J.W.Y.C.; manuscript preparation, T.L.K.; manuscript

editing, B.D., J.J.W.Y.C., S.T.B.; manuscript review, T.L.K.,

B.D., J.J.W.Y.C., S.T.B.

Received March 30, 1998; revision requested June 17, 1998; revision received July 24, 1998; accepted September 28,
1998.
References
TOP
Abstract
Introduction
RESULTS
DISCUSSION
References

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Acute Pancreatitis Transplant Rejection

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Acute Pancreatic Transplant Rejection: Evaluation with Dynamic Contrast-enh...red with Histopathologic Analysis -- Krebs et al.

210 (2): 437 -- Radiology

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