66 yo white male had a kidney transplant March 15 because of chronic renal failure due to cystic kidneys and analgetic abuse. He was under treatment with cyclosporin, Crea levels in the high normal range.
Presented to a regional hospital with pancreatitis and was promptly referred to our Medical Department for treatment and ICU care. Initial Ranson was 4, after 48h 3. Stable cardiorespiratory function. Initial Ultrasound demonstrated gallstones with a dilated CBD, an ERCP (with papillotomy) was performed and sludge evacuated.
Laboratory and diagnostic studies
CT-scan could not be carried out with contrast due to elevated Creatinin, demonstrated clear inflammation of whole pancreas and ascites, clear evidence of necrosis can not be affirmed or ruled out (as you all know). CRP is elevated >300 in serial blood tests, Lc 10-13’000.
Patient is afebrile, not intubated, cardiac function stable without pressors. Receives conservative treatment with imipenem and octreoitide. Immunosuppressive treatment with cyclosporin and steroids. I was consulted to see patient.
Suggested MRI to know more about possible necrosis. Radiologist describes patchy necrosis (up to 4mm in diameter) throughout the whole pancreas without larger areas.
What to do now? Immunosuppressed patient with possible(!) necrotizing pancreatitis, stable, not clearly improving.
Literature search does not divulge much information although a very good article by Slakey (Management of severe pancreatitis in renal transplant recepients.) comprising the experience of Milwaukee and Oxford transplant centers suggests good results with early vs. late operation (necrosectomy) in necrotizing pancreatitis for this group of patients.
Would appreciate your suggestions and experience.
1. Would you operate and when?
2. What are your regimens of conservative treatment in pancreatitis?