Evaluation of elevated lipase or amylase in pancreas transplant recipients

SPK: simultaneous pancreas-kidney; DSA: donor-specific antibody; dd-cfDNA: donor-derived cell-free deoxyribonucleic acid; CMV: cytomegalovirus; EBV: Epstein-Barr virus; BKPyV: BK polyomavirus; CT: computed tomography; IV: intravenous.

* Refer to UpToDate content on the evaluation of the adult with abdominal pain in the emergency department.

¶ Some experts may not repeat serum lipase and amylase levels if they are markedly elevated (>2 to 3 times normal).

Δ In pancreas recipients with elevated serum lipase and/or amylase levels who have an elevated serum creatinine level, elevated fasting plasma glucose level, de novo DSA or increase in DSA titer compared with pretransplant levels, or elevated plasma dd-cfDNA level (>1%), a presumptive diagnosis of acute pancreas rejection can be made. However, confirmation of the diagnosis requires a pancreas allograft biopsy. A subtherapeutic blood tacrolimus (or cyclosporine) level may suggest nonadherence or another factor (such as malabsorption) and raise suspicion for the diagnosis of acute rejection.

◊ The choice of imaging study varies depending upon the timing of presentation and presence or absence of abdominal symptoms. For patients within the early preoperative period (ie, first 3 months posttransplant) or who have abdominal symptoms or signs, we prefer CT of the abdomen/pelvis with oral and IV contrast. For patients who are beyond the early preoperative period and who do not have abdominal symptoms or signs, pancreas allograft ultrasound with Doppler study or CT of the abdomen/pelvis with oral and IV contrast is a reasonable choice.

§ The detection of CMV, EBV, or BKPyV viremia is important as the management of new viremia is different from that for acute pancreas rejection and involves antiviral therapy and a reduction, rather than augmentation, in immunosuppression. Some clinicians would treat new viremia first before considering a diagnosis or initiating treatment of rejection. Other clinicians would base decisions on the clinical setting and extent of viremia. As an example, in a patient with elevated pancreatic enzyme levels who has recently discontinued CMV prophylaxis and is found to have low level CMV viremia, some authors would treat the viremia while proceeding to a pancreas allograft biopsy and treating for acute rejection if present. Refer to UpToDate content on the treatment of CMV, EBV, and BKPyV viremia and disease in kidney transplant recipients.

¥ In SPK recipients, a kidney allograft biopsy is frequently performed first since it is technically easier to perform and there is approximately 60% concordance between the kidney and pancreas allograft biopsy. If the kidney allograft biopsy does not reveal evidence of rejection and serum lipase and/or amylase levels remain elevated, a pancreas allograft biopsy may be warranted.