Autoimmune diabetes recurrence should be routinely monitored after pancreas transplantation

Abstract

Autoimmune type 1 diabetes recurrence in pancreas grafts was first described 30 years ago, but it is not yet completely understood. In fact, the number of transplants affected and possibly lost due to this disease may be falsely low. There may be insufficient awareness to this entity by clinicians, leading to underdiagnosis. Some authors estimate that half of the immunological losses in pancreas transplantation are due to autoimmunity. Pancreas biopsy is the gold standard for the definitive diagnosis. However, as an invasive procedure, it is not the ideal approach to screen the disease. Pancreatic autoantibodies which may be detected early before graft dysfunction, when searched for, are probably the best initial tool to establish the diagnosis. The purpose of this review is to revisit the autoimmune aspects of type 1 diabetes and to analyse data about the identified autoantibodies, as serological markers of the disease. Therapeutic strategies used to control the disease, though with unsatisfactory results, are also addressed. In addition, the author's own experience with the prospective monitoring of pancreatic autoantibodies after transplantation and its correlation with graft outcome will be discussed.

Autoimmune Diabetes Recurrence After Pancreas Transplantation: Diagnosis, Management, and Literature Review

“…In our series, before pancreas transplantation, 15.8% and 7.3% of patients presented increased GADA and IA-2A values, respectively. These data are similar to those described by Martins et al [13], who reported that 21.5% of patients were positive for GADA, 10.4% were ICA-positive, and 3% were IAA-positive before SPK transplantation, GADA being the most frequently positive autoimmune marker [13]. However, none of the patients who were positive for GADA and IA-2A before the transplant had a subsequent T1DM recurrence.…”

“…However, none of the patients who were positive for GADA and IA-2A before the transplant had a subsequent T1DM recurrence. Hence, pretransplant autoantibody positivity does not seem to predict future pancreas graft endocrine function or diabetes recurrence [13,22].…”

“…After SPK transplantation, pancreatic autoantibodies can persist, disappear, or reappear [9,12,22,29], and their pre-transplantation positivity does not influence pancreas graft survival [13]. The positivity of these autoantibodies is a good predictor of the appearance of autoimmune diabetes, and autoantibodies sometimes precede hyperglycemia by several months or years [27].…”

“…Diagnosis of T1DM recurrence after pancreas transplantation includes clinical approach, islet cell autoantibody measurement, and pancreas graft biopsy [13]. The positivity of these autoantibodies may raise the suspicion of autoimmune diabetes, and the positivity of 2 or more autoantibodies is highly predictive of the development of T1DM [14].…”

“…The positivity of these autoantibodies may raise the suspicion of autoimmune diabetes, and the positivity of 2 or more autoantibodies is highly predictive of the development of T1DM [14]. Pancreas graft biopsy showing insulitis is the histological hallmark that leads to diagnostic confirmation [13].…”