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Kosaka S, Muraji T, Ohtani H, Harumatsu T, Shimizu S, Toma M, Yanai T, Ieiri S. Lymphangiogenesis in the liver of biliary atresia. BMC Gastroenterol 2024; 24:266. [PMID: 39143576 PMCID: PMC11325597 DOI: 10.1186/s12876-024-03370-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 08/13/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND Lymphatic vessels (LVs) play a crucial role in immune reactions by serving as the principal conduits for immune cells. However, to date, no study has analyzed the morphological changes in the LVs of patients with biliary atresia (BA). In this study, we aimed to determine the morphological changes in the LVs irrigating the liver in patients with BA, elucidate their correlations with the morphology of the portal vein (PV) branches, and discuss their etiopathogenetic significance. METHODS Morphometric analyses of liver biopsy specimens from patients treated between 1986 and 2016 were performed. The parameters measured were as follows: the whole liver area of the specimen, fibrotic area, number of LVs, LVs without patent lumen (designated as Ly0) and PV branches, and diameters of the LVs with patent lumen and the PVs. RESULTS The numbers of LVs, Ly0, and PV branches per unit area of the whole liver specimen were significantly higher in patients with BA than in control participants with liver disease and those with normal livers. However, no correlation was observed between the fibrotic area and the average diameter of LVs or PVs, and between the fibrotic area and the number of LVs or PV branches. Furthermore, no correlation was observed between the total number of LVs and the number of PV branches. CONCLUSIONS The present study showed a significant increase in the number of total LVs and Ly0, characterized by a high Ly0 to total LVs ratio, suggesting that lymphangiogenesis occurs in the liver of patients with BA.
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Affiliation(s)
- Seitaro Kosaka
- Department of Pediatric Surgery, Ibaraki Children's Hospital, Ibaraki, Japan.
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 3-3-13 Hongo, Bunkyo-Ku, Tokyo, Japan.
| | - Toshihiro Muraji
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Haruo Ohtani
- Department of Pathology, Ibaraki Children's Hospital, Ibaraki, Japan
| | - Toshio Harumatsu
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Sakika Shimizu
- Department of Pediatric Surgery, Ibaraki Children's Hospital, Ibaraki, Japan
| | - Miki Toma
- Department of Pediatric Surgery, Ibaraki Children's Hospital, Ibaraki, Japan
| | - Toshihiro Yanai
- Department of Pediatric Surgery, Ibaraki Children's Hospital, Ibaraki, Japan
| | - Satoshi Ieiri
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
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2
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Miyazawa M, Yanagi M, Chiba T, Kido H, Matsuo T, Nishitani M, Orita N, Takata N, Hayashi T, Seki A, Nakagawa H, Nio K, Terashima T, Iida N, Yamada S, Takatori H, Shimakami T, Arai K, Yamashita T, Mizukoshi E, Honda M, Yamashita T. Post-allogeneic Hematopoietic Stem Cell Transplantation Portal Hypertension Not Associated with Liver Cirrhosis, Veno-occlusive Disease, or Graft-versus-host Disease. Intern Med 2024; 63:1563-1568. [PMID: 37839881 PMCID: PMC11189707 DOI: 10.2169/internalmedicine.2489-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/30/2023] [Indexed: 10/17/2023] Open
Abstract
We herein report a rare case of idiopathic portal hypertension (IPH)-like disease that developed after allogeneic hematopoietic stem cell transplantation (allo-HSCT). A 53-year-old woman who underwent allo-HSCT for acute myeloid leukemia showed portal hypertension with radiological and histopathological findings consistent with IPH, distinct from veno-occlusive disease (VOD) and graft-versus-host disease (GVHD) of the liver. This case highlights the importance of considering IPH-like disease as a potential cause of portal hypertension after allo-HSCT. Awareness of this complication can aid in the early diagnosis and appropriate management of patients post allo-HSCT.
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Affiliation(s)
- Masaki Miyazawa
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | - Masahiro Yanagi
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | - Tomoyoshi Chiba
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | - Hidenori Kido
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | - Toshiki Matsuo
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | - Masaki Nishitani
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | - Noriaki Orita
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | - Noboru Takata
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | - Tomoyuki Hayashi
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | - Akihiro Seki
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | | | - Kouki Nio
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | | | - Noriho Iida
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | - Shinya Yamada
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | - Hajime Takatori
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | | | - Kuniaki Arai
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | | | | | - Masao Honda
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | - Taro Yamashita
- Department of Gastroenterology, Kanazawa University Hospital, Japan
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3
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Beyler O, Demir C. Pulse Methylprednisolone-Induced Sinus Bradycardia: A Case Report. EXP CLIN TRANSPLANT 2023; 21:921-924. [PMID: 38140936 DOI: 10.6002/ect.2023.0095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Corticosteroids have a wide range of uses. The most commonadverse side effectsofhigh-dosepulse steroids are hyperglycemia, gastrointestinal intolerance, and psychiatric symptoms. Cardiac arrhythmias have been reported in patients who receive high-dose steroid therapy. Bradycardia is a rare adverse side effect of pulse steroid therapy. We present the case of a 57-year-old male patient who developed symptomatic sinus bradycardia after he received pulse methylprednisolone therapy as treatment for graft-versushost disease. The patient's pulse steroid therapy was discontinued, and the dose of methylprednisolone was reduced to 100 mg/day. He was treated conservatively and with close observation; the patient's heart rate increased to 68 beats/min after 1 day, and then to 78 beats/min. The diagnosis of methylprednisolone-induced bradycardia was made after exclusion of other common etiologies of sinus bradycardia. This case report demonstrates the importance of careful cardiovascular monitoring in patients who receive high-dose methylprednisolone because of dose-related cardiovascular risks.
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Affiliation(s)
- Ozlem Beyler
- From the Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
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4
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Stueck AE, Fiel MI. Hepatic graft-versus-host disease: what we know, when to biopsy, and how to diagnose. Hum Pathol 2023; 141:170-182. [PMID: 37541449 DOI: 10.1016/j.humpath.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/19/2023] [Accepted: 07/24/2023] [Indexed: 08/06/2023]
Abstract
Graft-versus-host disease (GVHD) is one of the serious complications that may develop after hematopoietic cell transplantation (HCT), for hematologic malignancies, solid organ transplantation, and other hematologic disorders. GVHD develops due to T lymphocytes present in the graft attacking the host antigens, which results in tissue damage. A significant number of HCT patients develop acute or chronic GVHD, which may affect multiple organs including the liver. The diagnosis of hepatic GVHD (hGVHD) is challenging as many other conditions in HCT patients may lead to liver dysfunction. Particularly challenging among the various conditions that give rise to liver dysfunction is differentiating sinusoidal obstruction syndrome and drug-induced liver injury (DILI) from hGVHD on clinical grounds and laboratory tests. Despite the minimal risks involved in performing a liver biopsy, the information gleaned from the histopathologic changes may help in the management of these very complex patients. There is a spectrum of histologic features found in hGVHD, and most involve histopathologic changes affecting the interlobular bile ducts. These include nuclear and cytoplasmic abnormalities including dysmorphic bile ducts, apoptosis, and cholangiocyte necrosis, among others. The hepatitic form of hGVHD typically shows severe acute hepatitis. With chronic hGVHD, there is progressive bile duct loss and eventually fibrosis. Accurate diagnosis of hGVHD is paramount so that timely treatment and management can be initiated. Techniques to prevent and lower the risk of GVHD from developing have recently evolved. If a diagnosis of acute GVHD is made, the first-line of treatment is steroids. Recurrence is common and steroid resistance or dependency is not unusual in this setting. Second-line therapies differ among institutions and have not been uniformly established. The development of GVHD, particularly hGVHD, is associated with increased morbidity and mortality.
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Affiliation(s)
- Ashley E Stueck
- Department of Pathology, Dalhousie University, 715 - 5788 University Avenue, Halifax, NS, B3H 2Y9, Canada.
| | - M Isabel Fiel
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA.
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5
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Characterization of Hepatic Dysfunction in Subjects Diagnosed With Chronic GVHD by NIH Consensus Criteria. Transplant Cell Ther 2022; 28:747.e1-747.e10. [DOI: 10.1016/j.jtct.2022.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/14/2022] [Accepted: 07/16/2022] [Indexed: 11/23/2022]
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6
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Chagué C, Gautier T, Dal Zuffo L, Pais de Barros J, Wetzel A, Tarris G, Pallot G, Martin L, Valmary‐Degano S, Deckert V, Lagrost L, Daguindau E, Saas P. High-density lipoprotein infusion protects from acute graft-versus-host disease in experimental allogeneic hematopoietic cell transplantation. Am J Transplant 2022; 22:1350-1361. [PMID: 35038785 PMCID: PMC9306461 DOI: 10.1111/ajt.16960] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 01/07/2022] [Accepted: 01/12/2022] [Indexed: 01/25/2023]
Abstract
Acute graft-versus-host disease (aGVHD) is a major limitation of the therapeutic potential of allogeneic hematopoietic cell transplantation. Lipopolysaccharides (LPS) derived from intestinal gram-negative bacteria are well-known aGVHD triggers and amplifiers. Here, we explored the LPS metabolism in aGVHD mouse models using an innovative quantification method. We demonstrated that systemic LPS accumulation after transplantation was due, at least partly, to a defect in its clearance through lipoprotein-mediated transport to the liver (i.e., the so-called reverse LPS transport). After transplantation, reduced circulating HDL concentration impaired LPS neutralization and elimination through biliary flux. Accordingly, HDL-deficient (Apoa1tm1Unc ) recipient mice developed exacerbated aGVHD. Repeated administration of HDL isolated from human plasma significantly decreased the mortality and the severity of aGVHD. While the potential role of HDL in scavenging circulating LPS was examined in this study, it appears that HDL plays a more direct immunomodulatory role by limiting or controlling aGVHD. Notably, HDL infusion mitigated liver aGVHD by diminishing immune infiltration (e.g., interferon-γ-secreting CD8+ T cells and non-resident macrophages), systemic and local inflammation (notably cholangitis). Hence, our results revealed the interest of HDL-based therapies in the prevention of aGVHD.
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Affiliation(s)
- Cécile Chagué
- University Bourgogne Franche‐ComtéINSERM, EFS BFCUMR1098 RIGHT Interactions Greffon‐Hôte‐Tumeur/Ingénierie Cellulaire et GéniqueLabEX LipSTICFHU INCREASEBesançonFrance
| | - Thomas Gautier
- University Bourgogne Franche‐ComtéINSERMLNC UMR1231LabEX LipSTICDijonFrance
| | - Ludivine Dal Zuffo
- University Bourgogne Franche‐ComtéINSERM, EFS BFCUMR1098 RIGHT Interactions Greffon‐Hôte‐Tumeur/Ingénierie Cellulaire et GéniqueLabEX LipSTICFHU INCREASEBesançonFrance
| | | | - Audrey Wetzel
- University Bourgogne Franche‐ComtéINSERM, EFS BFCUMR1098 RIGHT Interactions Greffon‐Hôte‐Tumeur/Ingénierie Cellulaire et GéniqueLabEX LipSTICFHU INCREASEBesançonFrance
| | - Georges Tarris
- University Bourgogne Franche‐ComtéINSERM, EFS BFCUMR1098 RIGHT Interactions Greffon‐Hôte‐Tumeur/Ingénierie Cellulaire et GéniqueLabEX LipSTICFHU INCREASEBesançonFrance,Service d’Anatomie et Cytologie PathologiquesCHU DijonDijonFrance
| | - Gaëtan Pallot
- University Bourgogne Franche‐ComtéINSERMLNC UMR1231LabEX LipSTICDijonFrance
| | - Laurent Martin
- University Bourgogne Franche‐ComtéINSERM, EFS BFCUMR1098 RIGHT Interactions Greffon‐Hôte‐Tumeur/Ingénierie Cellulaire et GéniqueLabEX LipSTICFHU INCREASEBesançonFrance,Service d’Anatomie et Cytologie PathologiquesCHU DijonDijonFrance
| | | | - Valérie Deckert
- University Bourgogne Franche‐ComtéINSERMLNC UMR1231LabEX LipSTICDijonFrance
| | - Laurent Lagrost
- University Bourgogne Franche‐ComtéINSERMLNC UMR1231LabEX LipSTICDijonFrance
| | - Etienne Daguindau
- University Bourgogne Franche‐ComtéINSERM, EFS BFCUMR1098 RIGHT Interactions Greffon‐Hôte‐Tumeur/Ingénierie Cellulaire et GéniqueLabEX LipSTICFHU INCREASEBesançonFrance,Service d’HématologieCHU BesançonBesançonFrance
| | - Philippe Saas
- University Bourgogne Franche‐ComtéINSERM, EFS BFCUMR1098 RIGHT Interactions Greffon‐Hôte‐Tumeur/Ingénierie Cellulaire et GéniqueLabEX LipSTICFHU INCREASEBesançonFrance
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7
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Modulating endothelial cells with EGFL7 to diminish aGVHD after allogeneic bone marrow transplantation in mice. Blood Adv 2021; 6:2403-2408. [PMID: 34654057 PMCID: PMC9006300 DOI: 10.1182/bloodadvances.2021005498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/27/2021] [Indexed: 11/20/2022] Open
Abstract
Treatment of GVHD with EGFL7 protein results in decreased disease severity and prolonged survival. EGFL7 treatment improved immune reconstitution and did not inhibit graft-versus-leukemia effect.
Acute graft-versus-host disease (aGVHD) is the second most common cause of death after allogeneic hematopoietic stem cell transplantation (allo-HSCT), underscoring the need for novel therapies. Based on previous work that endothelial cell dysfunction is present in aGVHD and that epidermal growth factor-like domain 7 (EGFL7) plays a significant role in decreasing inflammation by repressing endothelial cell activation and T-cell migration, we hypothesized that increasing EGFL7 levels after allo-HSCT will diminish the severity of aGVHD. Here, we show that treatment with recombinant EGFL7 (rEGFL7) in 2 different murine models of aGVHD decreases aGVHD severity and improves survival in recipient mice after allogeneic transplantation with respect to controls without affecting graft-versus-leukemia effect. Furthermore, we showed that rEGFL7 treatment results in higher thymocytes, T, B, and dendritic cell counts in recipient mice after allo-HSCT. This study constitutes a proof of concept of the ability of rEGFL7 therapy to reduce GHVD severity and mortality after allo-HSCT.
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8
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Bouazzaoui A, Abdellatif AAH, Al-Allaf FA, Bogari NM, Taher MM, Athar M, Schubert T, Habeebullah TM, Qari SH. Compound A Increases Cell Infiltration in Target Organs of Acute Graft-versus-Host Disease (aGVHD) in a Mouse Model. Molecules 2021; 26:molecules26144237. [PMID: 34299512 PMCID: PMC8303851 DOI: 10.3390/molecules26144237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 11/22/2022] Open
Abstract
Systemic steroids are used to treat acute graft-versus-host disease (aGVHD) caused by allogenic bone marrow transplantation (allo-BMT); however, their prolonged use results in complications. Hence, new agents for treating aGVHD are required. Recently, a new compound A (CpdA), with anti-inflammatory activity and reduced side effects compared to steroids, has been identified. Here, we aimed to determine whether CpdA can improve the outcome of aGVHD when administered after transplantation in a mouse model (C57BL/6 in B6D2F1). After conditioning with 9Gy total body irradiation, mice were infused with bone marrow (BM) cells and splenocytes from either syngeneic (B6D2F1) or allogeneic (C57BL/6) donors. The animals were subsequently treated (3 days/week) with 7.5 mg/kg CpdA from day +15 to day +28; the controls received 0.9% NaCl. Thereafter, the incidence and severity of aGVHD in aGVHD target organs were analyzed. Survival and clinical scores did not differ significantly; however, CpdA-treated animals showed high cell infiltration in the target organs. In bulk mixed lymphocyte reactions, CpdA treatment reduced the cell proliferation and expression of inflammatory cytokines and chemokines compared to controls, whereas levels of TNF, IL-23, chemokines, and chemokine receptors increased. CpdA significantly reduced proliferation in vitro but increased T cell infiltration in target organs.
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Affiliation(s)
- Abdellatif Bouazzaoui
- Department of Medical Genetics, Faculty of Medicine, Umm Al-Qura University, Makkah 21955, Saudi Arabia; (F.A.A.-A.); (N.M.B.); (M.M.T.); (M.A.)
- Science and Technology Unit, Umm Al-Qura University, Makkah 21955, Saudi Arabia
- Medical Clinic 3–Hematology/Oncology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany
- Correspondence: or ; Tel.: +966-571297636
| | - Ahmed A. H. Abdellatif
- Department of Pharmaceutics, College of Pharmacy, Qassim University, Qassim 51452, Saudi Arabia;
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Al-Azhar University, Assiut 71524, Egypt
| | - Faisal A. Al-Allaf
- Department of Medical Genetics, Faculty of Medicine, Umm Al-Qura University, Makkah 21955, Saudi Arabia; (F.A.A.-A.); (N.M.B.); (M.M.T.); (M.A.)
| | - Neda M. Bogari
- Department of Medical Genetics, Faculty of Medicine, Umm Al-Qura University, Makkah 21955, Saudi Arabia; (F.A.A.-A.); (N.M.B.); (M.M.T.); (M.A.)
| | - Mohiuddin M. Taher
- Department of Medical Genetics, Faculty of Medicine, Umm Al-Qura University, Makkah 21955, Saudi Arabia; (F.A.A.-A.); (N.M.B.); (M.M.T.); (M.A.)
- Science and Technology Unit, Umm Al-Qura University, Makkah 21955, Saudi Arabia
| | - Mohammad Athar
- Department of Medical Genetics, Faculty of Medicine, Umm Al-Qura University, Makkah 21955, Saudi Arabia; (F.A.A.-A.); (N.M.B.); (M.M.T.); (M.A.)
- Science and Technology Unit, Umm Al-Qura University, Makkah 21955, Saudi Arabia
| | - Thomas Schubert
- Institut für Angewandte Pathologie Speyer, Alter Postweg 1, 67346 Speyer, Germany;
| | - Turki M. Habeebullah
- Environment and Health Research Department, The Custodian of the Two Holy Mosques Institute for Hajj and Umrah Research, Umm Al-Qura University, Makkah 21955, Saudi Arabia;
| | - Sameer H. Qari
- Biology Department, Aljumum University College, Umm Al-Qura University, Makkah 21955, Saudi Arabia;
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Zhao JY, Liu SN, Xu LP, Zhang XH, Wang Y, Chen YH, Liu KY, Huang XJ, Mo XD. Ruxolitinib is an effective salvage treatment for multidrug-resistant graft-versus-host disease after haploidentical allogeneic hematopoietic stem cell transplantation without posttransplant cyclophosphamide. Ann Hematol 2020; 100:169-180. [PMID: 33159239 DOI: 10.1007/s00277-020-04273-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 05/04/2020] [Indexed: 12/24/2022]
Abstract
The purpose of our study is to identify the efficacy of ruxolitinib in human leukocyte antigen (HLA) haploidentical hematopoietic stem cell transplantation (haplo-HSCT) recipients with multidrug-resistant (MDR)-graft-versus-host disease (GVHD, n = 34). MDR-GVHD was defined as GVHD showing no improvement after at least 3 types of treatments. The median number of previous GVHD-therapies was 4 for both MDR-acute GVHD (aGVHD) and MDR-chronic GVHD (cGVHD). For MDR-aGVHD (n = 15), the median time to response was 10 days (range 2 to 65), and the overall response rate (ORR) was 60.0% (9/15), including 40.0% (6/15) complete response (CR) and 20.0% (3/15) partial response (PR). The 1-year probability of overall survival after ruxolitinib was 66.7%. The rates of hematologic and infectious toxicities were 73.3% and 46.7% after ruxolitinib treatment. For MDR-cGVHD (n = 19), the median time to response was 29 days (range 6 to 175), and the ORR was 89.5% (17/19), including 26.3% (5/19) CR and 63.2% (12/19) PR. All patients remained alive until our last follow-up. The rates of hematologic and infectious toxicities were 36.8% and 47.4% after ruxolitinib treatment. Ruxolitinib is an effective salvage treatment for MDR-GVHD in haplo-HSCT recipients.
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Affiliation(s)
- Jiao-Yu Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Department of Hematology, the Second Hospital of Shanxi Medical University, Taiyuan, 030001, China
| | - Si-Ning Liu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Lan-Ping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Research Unit of Key Technique for Diagnosis and Treatments of Hematologic Malignancies, Chinese Academy of Medical Sciences, Beijing, 2019RU029, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yu-Hong Chen
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Kai-Yan Liu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Research Unit of Key Technique for Diagnosis and Treatments of Hematologic Malignancies, Chinese Academy of Medical Sciences, Beijing, 2019RU029, China.,Peking-Tsinghua Center for Life Sciences, Beijing, 100044, China
| | - Xiao-Dong Mo
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China. .,Research Unit of Key Technique for Diagnosis and Treatments of Hematologic Malignancies, Chinese Academy of Medical Sciences, Beijing, 2019RU029, China.
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10
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Suda K, Muraji T, Ohtani H, Aiyoshi T, Sasaki T, Toma M, Yanai T. Histological significance of hepatitis-like findings in biliary atresia: An analysis of 34 Japanese cases. Pediatr Int 2019; 61:364-368. [PMID: 30811786 DOI: 10.1111/ped.13816] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 12/21/2018] [Accepted: 02/23/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hepatocellular injury including multinuclear changes are common histological features in biliary atresia (BA), as well as in neonatal hepatitis. To date, however, no reports have examined how those findings correlate with the prognosis of BA. We clarified the clinical implications of hepatitis-related changes in BA on histological analysis. METHODS We retrospectively reviewed 34 cases of BA treated over the past 30 years at Ibaraki Children's Hospital. Liver biopsy specimens during Kasai procedures were evaluated for hepatocyte multinuclear change, ballooning, and acidophilic body, hereby defined as hepatitis-like findings (HLF). Each finding was semi-quantitatively scored as 0-2, and their sum was defined as the HLF score, ranging from 0 to 6. We examined the correlation between HLF score and total bilirubin (T-Bil), direct bilirubin (D-Bil), and other liver function test results at the Kasai procedure, as well as 1 week, and 1, 3, and 6 months after the Kasai procedure. Subsequently, HLF score was compared between native liver survivors (NLS; n = 16) and non-NLS (n = 18) for long-term analyses. RESULTS Hepatitis-like findings score except for aspartate aminotransferase (AST), had no correlation with the preoperative data. HLF score was positively correlated, however, with T-Bil, D-Bil, and AST at 1 week and 1 month after the Kasai procedure (1 week: P = 0.009, 0.023, and 0.019; 1 month: 0.022, 0.019, and 0.013, respectively). HLF score was not significantly different between the NLS and non-NLS groups. CONCLUSION Higher HLF score at Kasai procedure is an indicator of poor liver function at short-term follow up.
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Affiliation(s)
- Kazuto Suda
- Department of Pediatric Surgery, Ibaraki Children's Hospital, Mito, Ibaraki, Japan
| | - Toshihiro Muraji
- Department of Pediatric Surgery, Ibaraki Children's Hospital, Mito, Ibaraki, Japan.,Department of Pediatric Surgery, Kirishima Medical Center affiliated with Research Field in Medical and Health Sciences, Kagoshima University, Kirishima, Kagoshima, Japan
| | - Haruo Ohtani
- Department of Pathology, Ibaraki Children's Hospital, Mito, Ibaraki, Japan
| | - Tsubasa Aiyoshi
- Department of Pediatric Surgery, Ibaraki Children's Hospital, Mito, Ibaraki, Japan
| | - Takato Sasaki
- Department of Pediatric Surgery, Ibaraki Children's Hospital, Mito, Ibaraki, Japan
| | - Miki Toma
- Department of Pediatric Surgery, Ibaraki Children's Hospital, Mito, Ibaraki, Japan
| | - Toshihiro Yanai
- Department of Pediatric Surgery, Ibaraki Children's Hospital, Mito, Ibaraki, Japan
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11
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Mourad N, Michel RP, Marcus VA. Pathology of Gastrointestinal and Liver Complications of Hematopoietic Stem Cell Transplantation. Arch Pathol Lab Med 2019; 143:1131-1143. [PMID: 30838881 DOI: 10.5858/arpa.2018-0282-ra] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
CONTEXT.— Despite advances in therapeutic and preventive measures, hematopoietic stem cell transplant recipients remain at risk for a variety of gastrointestinal and liver complications. OBJECTIVE.— To detail the pathologic features of the various gastrointestinal and liver complications occurring after hematopoietic stem cell transplantation in relation to their clinical context. The specific complications covered include graft-versus-host disease, mycophenolate mofetil-induced injury, timeline of infections, neutropenic enterocolitis, gastrointestinal thrombotic microangiopathy, sinusoidal obstruction syndrome, hepatic iron overload, and the controversy around cord colitis syndrome. DATA SOURCES.— The content of this article is based on pertinent peer-reviewed articles in PubMed, relevant textbooks, and on the authors' personal experiences. CONCLUSIONS.— The final histopathologic diagnosis requires the integration of clinical and histologic findings and the exclusion of other competing causes of injury. Review of the clinical data, including the original disease pretransplant, the type of transplant, the timing of the gastrointestinal and/or liver manifestations, the timing of the biopsy after transplant, the presence of graft-versus-host disease in other organs and sites, the list of drug regimens, and the clinical and laboratory evidence of infection, is the key to reaching the proper histologic diagnosis.
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Affiliation(s)
- Nathalie Mourad
- Faculté de médecine, département de biologie moléculaire, de biochimie médicale et de pathologie, Université Laval, Hôpital du Saint-Sacrement - CHU de Québec, Québec, Québec, Canada (Dr Mourad); the Department of Pathology, McGill University and McGill University Health Center, Montreal, Quebec, Canada (Drs Michel and Marcus)
| | - René P Michel
- Faculté de médecine, département de biologie moléculaire, de biochimie médicale et de pathologie, Université Laval, Hôpital du Saint-Sacrement - CHU de Québec, Québec, Québec, Canada (Dr Mourad); the Department of Pathology, McGill University and McGill University Health Center, Montreal, Quebec, Canada (Drs Michel and Marcus)
| | - Victoria A Marcus
- Faculté de médecine, département de biologie moléculaire, de biochimie médicale et de pathologie, Université Laval, Hôpital du Saint-Sacrement - CHU de Québec, Québec, Québec, Canada (Dr Mourad); the Department of Pathology, McGill University and McGill University Health Center, Montreal, Quebec, Canada (Drs Michel and Marcus)
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12
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Ruggiu M, Bedossa P, Rautou PE, Bertheau P, Plessier A, Peffault de Latour R, Robin M, Sicre de Fontbrune F, Pagliuca S, Villate A, Xhaard A, Socié G, Michonneau D. Utility and Safety of Liver Biopsy in Patients with Undetermined Liver Blood Test Anomalies after Allogeneic Hematopoietic Stem Cell Transplantation: A Monocentric Retrospective Cohort Study. Biol Blood Marrow Transplant 2018; 24:2523-2531. [DOI: 10.1016/j.bbmt.2018.07.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 07/21/2018] [Indexed: 12/19/2022]
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13
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Stueck AE, Schiano TD, Fiel MI. Development of a novel histologic diagnostic algorithm for hepatic graft-versus-host disease. Mod Pathol 2018; 31:442-451. [PMID: 29192646 DOI: 10.1038/modpathol.2017.151] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 09/21/2017] [Accepted: 09/22/2017] [Indexed: 12/16/2022]
Abstract
The histopathologic diagnosis of hepatic graft-versus-host disease post bone marrow and stem cell transplantation can be challenging, but timely and unambiguous diagnosis is essential for appropriate patient management. To address this diagnostic dilemma, we identified histologic features specific for hepatic graft-versus-host disease and developed a diagnostic algorithm. Two hepatopathologists blindly evaluated 40 liver biopsies from patients with clinically and biologically confirmed graft-versus-host disease, as well as 44 controls, for percent bile duct loss, bile duct damage, intraepithelial lymphocytes, ductular reaction, acidophilic bodies/10 high power fields (HPF), cholestasis, portal and lobular inflammation, and endotheliitis. Compared with controls, graft-versus-host disease cases had significantly more bile duct loss (P<0.0001), bile duct damage (P=0.0002), cholestasis (P<0.0001), and acidophilic bodies/10 HPF (P=0.0006), as well as significantly less ductular reaction (P<0.0001). Significance was maintained with a drug-induced liver injury-only control group. No histologic differences were noted in acute versus chronic graft-versus-host disease, nor cholestatic versus hepatitic types. An algorithm to predict likelihood of graft-versus-host disease was developed, with a three-tiered scoring system: 1-2 not, 3-4 probable, and 5-8 unequivocal graft-versus-host disease. This algorithm had a sensitivity of 93%, specificity of 93%, and accuracy of 92%. We identified histologic features with specificity for hepatic graft-versus-host disease and developed a simple algorithm for pathologists to predict its likelihood, distinguishing this critical diagnosis promptly from mimickers having vastly different treatments and prognoses.
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Affiliation(s)
- Ashley E Stueck
- Dalhousie University, Department of Pathology, Halifax, NS, Canada
| | - Thomas D Schiano
- Icahn School of Medicine at Mount Sinai, Division of Liver Diseases, New York, NY, USA
| | - M Isabel Fiel
- Icahn School of Medicine at Mount Sinai, Department of Pathology, New York, NY, USA
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14
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Reddy P, Ferrara JL. Graft-Versus-Host Disease and Graft-Versus-Leukemia Responses. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00108-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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15
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Pollock G, Minuk GY. Diagnostic considerations for cholestatic liver disease. J Gastroenterol Hepatol 2017; 32:1303-1309. [PMID: 28106928 DOI: 10.1111/jgh.13738] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 01/16/2017] [Indexed: 12/17/2022]
Abstract
Cholestatic liver disease results from insufficient bile synthesis, secretion and/or flow through the biliary tract. Common presenting features include fatigue, pruritus, and cholestatic liver enzyme abnormalities wherein elevations of serum alkaline phosphatase and gamma-glutamyltransferases levels exceed those of alanine and aspartate aminotransferases. With prolonged cholestasis, fat soluble vitamin deficiencies, fibrosis, cirrhosis, and, on occasion, carcinoma of the biliary tract or liver can occur. Once mechanical obstruction to bile flow has been ruled out, the majority of causes can be classified as immune-mediated, infectious, or miscellaneous. Because specific therapeutic options are increasing for many causes of cholestasis, an accurate diagnosis is an important first step towards treatment. Thus, this review focuses on the diagnostic features of non-mechanical causes of cholestasis.
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Affiliation(s)
- Galia Pollock
- Section of Hepatology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gerald Y Minuk
- Section of Hepatology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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16
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McDonald GB, Tabellini L, Storer BE, Martin PJ, Lawler RL, Rosinski SL, Schoch HG, Hansen JA. Predictive Value of Clinical Findings and Plasma Biomarkers after Fourteen Days of Prednisone Treatment for Acute Graft-versus-host Disease. Biol Blood Marrow Transplant 2017; 23:1257-1263. [PMID: 28478120 DOI: 10.1016/j.bbmt.2017.04.029] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 04/29/2017] [Indexed: 11/30/2022]
Abstract
We examined the hypothesis that plasma biomarkers and concomitant clinical findings after initial glucocorticoid therapy can accurately predict failure of graft-versus-host-disease (GVHD) treatment and mortality. We analyzed plasma samples and clinical data in 165 patients after 14 days of glucocorticoid therapy and used logistic regression and areas under receiver-operating characteristic curves (AUC) to evaluate associations with treatment failure and nonrelapse mortality (NRM). Initial treatment of GVHD was unsuccessful in 49 patients (30%). For predicting GVHD treatment failure, the best clinical combination (total serum bilirubin and skin GVHD stage: AUC, .70) was competitive with the best biomarker combination (T cell immunoglobulin and mucin domain 3 [TIM3] and [interleukin 1 receptor family encoded by the IL1RL1 gene, ST2]: AUC, .73). The combination of clinical features and biomarker results offered only a slight improvement (AUC, .75). For predicting NRM at 1 year, the best clinical predictor (total serum bilirubin: AUC, .81) was competitive with the best biomarker combination (TIM3 and soluble tumor necrosis factor receptor-1 [sTNFR1]: AUC, .85). The combination offered no improvement (AUC, .85). Infection was the proximate cause of death in virtually all patients. We conclude that after 14 days of glucocorticoid therapy, clinical findings (serum bilirubin, skin GVHD) and plasma biomarkers (TIM3, ST2, sTNFR1) can predict failure of GVHD treatment and NRM. These biomarkers reflect counter-regulatory mechanisms and provide insight into the pathophysiology of GVHD reactions after glucocorticoid treatment. The best predictive models, however, exhibit inadequate positive predictive values for identifying high-risk GVHD cohorts for investigational trials, as only a minority of patients with high-risk GVHD would be identified and most patients would be falsely predicted to have adverse outcomes.
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Affiliation(s)
- George B McDonald
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Laura Tabellini
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Barry E Storer
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Biostatistics, University of Washington School of Medicine, Seattle, Washington
| | - Paul J Martin
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Richard L Lawler
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Steven L Rosinski
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - H Gary Schoch
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - John A Hansen
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington
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Imaging of Abdominal and Pelvic Manifestations of Graft-Versus-Host Disease After Hematopoietic Stem Cell Transplant. AJR Am J Roentgenol 2017; 209:33-45. [PMID: 28463600 DOI: 10.2214/ajr.17.17866] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Graft-versus-host disease (GVHD) is a common complication of hematopoietic stem cell transplant (HSCT). GVHD predominantly affects the skin, gastrointestinal system and hepatobiliary systems. Imaging findings in the gastrointestinal tract include bowel wall thickening with mucosal enhancement, mesenteric edema, and vascular engorgement. In the hepatobiliary system, hepatosplenomegaly, periportal edema, bile duct dilatation, and gallbladder and biliary wall thickening are seen. Although the imaging findings of GVHD are nonspecific, with a known history of HSCT, GVHD should be considered. CONCLUSION GVHD is a serious complication of HSCT, which involves multiple organ systems, with imaging manifestations most commonly seen in the gastrointestinal tract and hepatobiliary system. Knowledge of the imaging manifestations of GVHD, which alone may be relatively nonspecific, taken in conjunction with clinical history including the timing and type of HSCT, laboratory values, stool studies, and dermatologic findings can increase radiologist confidence in suggesting this diagnosis.
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18
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Hosoi H, Warigaya K, Murata S, Mushino T, Kuriyama K, Nishikawa A, Tamura S, Hatanaka K, Hanaoka N, Muragaki Y, Murata S, Nakakuma H, Sonoki T. Refractory Ascites with Liver Fibrosis Developed in Late Phase Allogeneic Hematopoietic Stem Cell Transplantation: Report of Three Patients. Hematol Rep 2016; 8:6482. [PMID: 27499838 PMCID: PMC4961872 DOI: 10.4081/hr.2016.6482] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 06/17/2016] [Indexed: 02/07/2023] Open
Abstract
We report cases of three patients of refractory ascites without other fluid retention that occurred around five months after allogeneic hematopoietic stem cell transplantation (allo-HSCT). All three patients expired and postmortem examinations revealed unexpected liver fibrosis lacking histological evidences of graft-versus-host-disease (GVHD). The three patients showed normal hepatic function and size before transplantation. During their clinical courses, serum biochemistry test showed no elevation of hepatic enzymes and bilirubin; however, imaging studies demonstrated hepatic atrophy at the onset of ascites. One of the liver specimens showed bile obstruction, which could be seen in hepatic damage by GVHD. Although ascites resulting from venoocclusive disease in early phase allo-HSCT is well documented, ascites associated with hepatic fibrosis in late phase allo-HCST has not been reported. Further clinico-pathological studies on similar patients should be required to ascertain refractory ascites associated with liver fibrosis after allo-HSCT.
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Affiliation(s)
- Hiroki Hosoi
- Department of Hematology and Oncology, Wakayama Medical University , Wakayama, Japan
| | - Kenji Warigaya
- Department of Human Pathology and Diagnostic Pathology, Wakayama Medical University , Wakayama, Japan
| | - Shogo Murata
- Department of Hematology and Oncology, Wakayama Medical University , Wakayama, Japan
| | - Toshiki Mushino
- Department of Hematology and Oncology, Wakayama Medical University , Wakayama, Japan
| | - Kodai Kuriyama
- Department of Hematology and Oncology, Wakayama Medical University , Wakayama, Japan
| | - Akinori Nishikawa
- Department of Hematology and Oncology, Wakayama Medical University , Wakayama, Japan
| | - Shinobu Tamura
- Department of Hematology and Oncology, Wakayama Medical University , Wakayama, Japan
| | - Kazuo Hatanaka
- Department of Hematology and Oncology, Wakayama Medical University , Wakayama, Japan
| | - Nobuyoshi Hanaoka
- Department of Hematology and Oncology, Wakayama Medical University , Wakayama, Japan
| | - Yasuteru Muragaki
- First Department of Pathology, Wakayama Medical University , Wakayama, Japan
| | - Shinichi Murata
- Department of Human Pathology and Diagnostic Pathology, Wakayama Medical University , Wakayama, Japan
| | - Hideki Nakakuma
- Department of Hematology and Oncology, Wakayama Medical University , Wakayama, Japan
| | - Takashi Sonoki
- Department of Hematology and Oncology, Wakayama Medical University , Wakayama, Japan
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19
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Salomao M, Dorritie K, Mapara MY, Sepulveda A. Histopathology of Graft-vs-Host Disease of Gastrointestinal Tract and Liver: An Update. Am J Clin Pathol 2016; 145:591-603. [PMID: 27247365 DOI: 10.1093/ajcp/aqw050] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Graft-vs-host disease (GVHD) is a donor T-cell-mediated disorder affecting the recipient's skin, gastrointestinal tract, lungs, and liver. It complicates up to 70% of hematopoietic cell transplantation and is associated with high morbidity and mortality rates. METHODS An extensive review of the literature has been performed to include the most current consensus on the histopathologic diagnosis of gastrointestinal and liver GVHD. RESULTS In this review, we present an overview of GVHD, with emphasis on the histopathologic evaluation of gastrointestinal and liver specimens, including the most important differential diagnoses and possible pitfalls. CONCLUSIONS Histopathologic examination remains the mainstay of diagnosis of gastrointestinal and liver GVHD and is interpreted in conjunction with clinical and laboratory data.
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Affiliation(s)
- Marcela Salomao
- From the Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY;
| | - Kathleen Dorritie
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center and the University of Pittsburgh Cancer Institute, Pittsburgh, PA
| | - Markus Y Mapara
- Department of Medicine, Division of Hematology/Oncology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Antonia Sepulveda
- From the Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY
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20
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How I treat acute graft-versus-host disease of the gastrointestinal tract and the liver. Blood 2016; 127:1544-50. [PMID: 26729898 DOI: 10.1182/blood-2015-10-612747] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 12/19/2015] [Indexed: 12/15/2022] Open
Abstract
Treatment of acute graft-versus-host disease (GVHD) has evolved from a one-size-fits-all approach to a more nuanced strategy based on predicted outcomes. Lower and time-limited doses of immune suppression for patients predicted to have low-risk GVHD are safe and effective. In more severe GVHD, prolonged exposure to immunosuppressive therapies, failure to achieve tolerance, and inadequate clinical responses are the proximate causes of GVHD-related deaths. This article presents acute GVHD-related scenarios representing, respectively, certainty of diagnosis, multiple causes of symptoms, jaundice, an initial therapy algorithm, secondary therapy, and defining futility of treatment.
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21
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Hematopoietic Stem Cell Transplantation. PATHOLOGY OF TRANSPLANTATION 2016. [PMCID: PMC7124099 DOI: 10.1007/978-3-319-29683-8_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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22
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Lim JY, Lee YK, Lee SE, Ju JM, Park G, Choi EY, Min CK. Attenuation of Hepatic Graft-versus-host Disease in Allogeneic Recipients of MyD88-deficient Donor Bone Marrow. Immune Netw 2015; 15:125-34. [PMID: 26140044 PMCID: PMC4486775 DOI: 10.4110/in.2015.15.3.125] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 05/22/2015] [Accepted: 05/30/2015] [Indexed: 12/28/2022] Open
Abstract
Acute graft-versus-host-disease (GVHD) is characterized by selective damage to the liver, the skin, and the gastrointestinal tract. Following allogeneic hematopoietic stem cell transplantation, donor bone marrow (BM) cells repopulate the immune system of the recipient. We previously demonstrated that the acute intestinal GVHD (iGVHD) mortality rate was higher in MyD88-deficient BM recipients than that in the control BM recipients. In the present study, the role of MyD88 (expressed by donor BM) in the pathophysiology of hepatic GVHD (hGVHD) was examined. Unlike iGVHD, transplantation with MyD88-deficient T-cell depleted (TCD) BM attenuated hGVHD severity and was associated with low infiltration of T cells into the liver of the recipients. Moreover, GVHD hosts, transplanted with MyD88-deficient TCD BM, exhibited markedly reduced expansion of CD11b+Gr-1+ myeloid-derived suppressor cells (MDSC) in the liver. Adoptive injection of the MDSC from wild type mice, but not MyD88-deficient mice, enhanced hepatic T cell infiltration in the MyD88-deficient TCD BM recipients. Pre-treatment of BM donors with LPS increased MDSC levels in the liver of allogeneic wild type BM recipients. In conclusion, hGVHD and iGVHD may occur through various mechanisms based on the presence of MyD88 in the non-T cell compartment of the allograft.
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Affiliation(s)
- Ji-Young Lim
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 137-701, Korea
| | - Young-Kwan Lee
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul 110-799, Korea
| | - Sung-Eun Lee
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 137-701, Korea
| | - Ji-Min Ju
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul 110-799, Korea
| | - Gyeongsin Park
- Department of Pathology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 137-701, Korea
| | - Eun Young Choi
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul 110-799, Korea
| | - Chang-Ki Min
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 137-701, Korea
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23
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Shulman HM, Cardona DM, Greenson JK, Hingorani S, Horn T, Huber E, Kreft A, Longerich T, Morton T, Myerson D, Prieto VG, Rosenberg A, Treister N, Washington K, Ziemer M, Pavletic SZ, Lee SJ, Flowers MED, Schultz KR, Jagasia M, Martin PJ, Vogelsang GB, Kleiner DE. NIH Consensus development project on criteria for clinical trials in chronic graft-versus-host disease: II. The 2014 Pathology Working Group Report. Biol Blood Marrow Transplant 2015; 21:589-603. [PMID: 25639770 DOI: 10.1016/j.bbmt.2014.12.031] [Citation(s) in RCA: 179] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 12/24/2014] [Indexed: 12/17/2022]
Abstract
The 2005 National Institute of Health (NIH) Consensus Conference outlined histopathological diagnostic criteria for the major organ systems affected by both acute and chronic graft-versus-host disease (GVHD). The 2014 Consensus Conference led to this updated document with new information from histopathological studies of GVHD in the gut, liver, skin, and oral mucosa and an expanded discussion of GVHD in the lungs and kidneys. The recommendations for final histological diagnostic categories have been simplified from 4 categories to 3: no GVHD, possible GVHD, and likely GVHD, based on better reproducibility achieved by combining the previous categories of "consistent with GVHD" and "definite GVHD" into the single category of "likely GVHD." Issues remain in the histopathological characterization of GVHD, particularly with respect to the threshold of histological changes required for diagnostic certainty. Guidance is provided for the incorporation of biopsy information into prospective clinical studies of GVHD, particularly with respect to biomarker validation.
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Affiliation(s)
- Howard M Shulman
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Diana M Cardona
- Department of Pathology, Duke University Medical Center, Durham, North Carolina
| | - Joel K Greenson
- Department of Pathology, University of Michigan, Ann Arbor, Michigan
| | - Sangeeta Hingorani
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Departments of Pediatrics, Gastroenterology and Pathology, University of Washington, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | - Thomas Horn
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Elisabeth Huber
- Institute of Pathology, University of Regensburg, Regensburg, Germany
| | - Andreas Kreft
- Institute of Pathology, University Medical Center Mainz, Mainz, Germany
| | - Thomas Longerich
- Institute of Pathology, University Hospital RWTH Aachen, Aachen, Germany
| | - Thomas Morton
- Departments of Pediatrics, Gastroenterology and Pathology, University of Washington, Seattle, Washington
| | - David Myerson
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pathology, University of Washington, Seattle, Washington
| | - Victor G Prieto
- Department of Pathology, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Avi Rosenberg
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Nathaniel Treister
- Division of Oral Medicine and Dentistry, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Kay Washington
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, Tennessee
| | - Mirjana Ziemer
- Department of Dermatology, University Hospital of Leipzig, Leipzig, Germany
| | - Steven Z Pavletic
- Experimental Transplantation and Immunology Branch, National Cancer Institute, Bethesda, Maryland
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Kirk R Schultz
- Department of Pediatrics, BC Children's Hospital/University of British Columbia, Vancouver, British Columbia
| | - Madan Jagasia
- Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Georgia B Vogelsang
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David E Kleiner
- Department of Pathology, University of Texas M.D. Anderson Cancer Center, Houston, Texas.
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24
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Hematopoietic stem cell transplantation: graft versus host disease and pathology of gastrointestinal tract, liver, and lung. Adv Anat Pathol 2014; 21:301-20. [PMID: 25105933 DOI: 10.1097/pap.0000000000000032] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Hematopoietic stem cell transplantation (HCT), formerly known as bone marrow transplantation, is an integral part of treatment for many hematological malignancies. HCT is associated with several complications and comorbidities with differential effects on a wide spectrum of organs and tissues. We present an update on HCT-associated complications such as graft versus host disease (GVHD) and infection, with focus on the surgical pathology of the gastrointestinal (GI) tract, liver, and lung. Although the grading system for GI tract acute GVHD was proposed 40 years ago, recent studies have shed light on minimal histologic criteria for diagnosis of GVHD, as well as its differential diagnosis, including histologic effects of various medications. GI dysfunction in autologous transplant recipients is increasingly appreciated and patients are often biopsied. Acute liver injury in HCT is often due to sinusoidal obstruction syndrome (previously known as venoocclusive disease), or acute GVHD. Liver dysfunction at later time posttransplantation may be associated with acute or chronic GVHD, iron overload, or other causes of hepatitis. Lung injury in HCT is multifactorial, and it remains crucially important to diagnose and treat pulmonary infections. The pulmonary biopsy yields clinically unsuspected diagnoses in the majority of cases and its utilization is likely to increase. The pathology of the skin and kidney in HCT patients are detailed in accompanying articles.
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25
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Consensus on the histopathological evaluation of liver biopsies from patients following allogeneic hematopoietic cell transplantation. Virchows Arch 2014; 464:175-90. [PMID: 24385287 DOI: 10.1007/s00428-013-1528-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 10/07/2013] [Accepted: 12/09/2013] [Indexed: 12/13/2022]
Abstract
After allogeneic hematopoietic cell transplantation (alloHCT) liver biopsy is performed for enigmatic liver disorders when noninvasive diagnostic steps have failed in establishing a definitive diagnosis. This document provides an updated consensus on the prerequisites for proper evaluation of liver biopsies in alloHCT patients and the histological diagnostic criteria for liver graft-versus-host disease (GvHD). The Working Group's recommendations for the histological diagnosis of liver GvHD were derived from the peer-reviewed literature and from the consensus diagnosis of a total of 30 coded liver biopsies. Acceptance of the recommendations was tested by a survey distributed to all HCT centers in Austria, Germany and Switzerland. Consensus was achieved for biopsy indications, methods of sample acquisition and processing, reporting and interpretation of biopsy findings. As GvHD is variably treated and the treatment modalities have changed over time, the panel endorses the use of more frequent biopsies in clinical studies in order to improve the present challenging clinical and diagnostic situation.
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26
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Current practice in diagnosis and treatment of acute graft-versus-host disease: results from a survey among German-Austrian-Swiss hematopoietic stem cell transplant centers. Biol Blood Marrow Transplant 2013; 19:767-76. [PMID: 23376495 DOI: 10.1016/j.bbmt.2013.01.018] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 01/23/2013] [Indexed: 12/19/2022]
Abstract
To assess current clinical practice in diagnosis and treatment of acute graft-versus-host disease (aGVHD), we performed a survey among German, Austrian, and Swiss allogeneic hematopoietic stem cell transplantation (allo-HSCT) centers. Thirty-four of 72 contacted centers (47%) completed both the diagnostic and therapeutic sections of the survey, representing 65% of allo-HSCT activity within the participating countries in 2011. Three pediatric centers answered as requested only the diagnostic part of the survey. In the presence of diarrhea and decreased oral intake after engraftment, only 4 centers (12%) do not perform any endoscopy before the start of immunosuppressive treatment. In case of a skin rash with the differential diagnosis of drug reaction, only 12 centers (35%) perform a skin biopsy up front, whereas 19 do so after failure of systemic steroids. In the presence of rapidly increasing cholestasis occurring without any other signs of aGVHD, 11 centers (32%) perform a liver biopsy up front and 14 only after failure of steroid treatment, whereas 9 centers do not perform a liver biopsy at all. Twenty centers (59%) use a percutaneous approach, 12 a transvenous approach, and 1 mini-laparoscopy for liver biopsies. First-line treatment of cutaneous aGVHD stage 1 consists of topical treatment alone in 17 of 31 responding centers (61%), whereas isolated cutaneous aGVHD stage III is treated with systemic steroids (prednisolone below 0.5 mg/kg/day n = 2, 0.5 to 1.0 mg/kg/day n = 10, above 1.0 to 2.5 mg/kg/day n = 19) without or with topical agents (steroids n = 10; calcineurin inhibitors n = 3). In gastrointestinal manifestations of aGVHD, 9 centers (29%) add topical to systemic steroids, and 3 consider topical steroids as the only treatment for mild gastrointestinal and cutaneous aGVHD. The choice of agent for second-line treatment as well as the sequence of administration are extremely heterogeneous, most likely due to a lack of convincing data published. Most frequently used are mycophenolate mofetil (n = 14) and extracorporeal photopheresis (n = 10). Our survey also demonstrates that clinicians chose salvage therapies for steroid-refractory aGVHD based on their centers' own clinical experience.
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Ali S, Pimentel JD, Munoz J, Shah V, McKinnon R, Divine G, Janakiraman N. Iron Overload in Allogeneic Hematopoietic Stem Cell Transplant Recipients. Arch Pathol Lab Med 2012; 136:532-8. [DOI: 10.5858/arpa.2011-0190-oa] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—Patients who undergo hematopoietic stem cell transplant are at an increased risk of developing iron overload.
Objectives.—To describe the effect of hepatic iron overload on hematopoietic stem cell transplant recipients and to validate the utility of histologic scoring system of iron granules in the liver.
Design.—Records of 154 post allogeneic hematopoietic stem cell transplant patients were reviewed. Forty-nine patients underwent liver biopsy. Histologic hepatic iron overload was defined as a score of 2 or greater (scale, 0–4).
Results.—Twenty-eight of 49 patients (57%) evaluated by liver biopsy had hepatic iron overload; 17 had moderate to severe hepatic iron overload (score, 3 or 4). In multivariate analysis, a significant correlation was discovered between hepatic iron overload and the number of transfusions (P < .001), posttransplant serum ferritin levels (P = .004), lactate dehydrogenase levels (P = .03), and the development of blood stream infections (P = .02). There was no correlation between hepatic iron overload and abnormal liver function test results. While 37 patients (76%) died after receiving a transplant, mortality was not influenced by hepatic iron overload but was significantly higher in older patients, in patients with lower serum albumin levels, higher serum bilirubin levels, and higher clinical grade of acute graft-versus-host disease (P = .04, P = .001, P = <.001, and P = .004, respectively).
Conclusions.—Hepatic iron overload is commonly identified in hematopoietic stem cell transplant patients and can be accurately diagnosed by liver biopsy. In addition, hepatic iron overload has been identified in patients receiving as few as 25 units of packed red blood cells, with elevated posttransplant serum ferritin levels, and with blood stream infections.
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Tuncer HH, Rana N, Milani C, Darko A, Al-Homsi SA. Gastrointestinal and hepatic complications of hematopoietic stem cell transplantation. World J Gastroenterol 2012; 18:1851-60. [PMID: 22563164 PMCID: PMC3337559 DOI: 10.3748/wjg.v18.i16.1851] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 11/15/2011] [Accepted: 12/31/2011] [Indexed: 02/06/2023] Open
Abstract
Recognition and management of gastrointestinal and hepatic complications of hematopoietic stem cell transplantation has gained increasing importance as indications and techniques of transplantation have expanded in the last few years. The transplant recipient is at risk for several complications including conditioning chemotherapy related toxicities, infections, bleeding, sinusoidal obstruction syndrome, acute and chronic graft-versus-host disease (GVHD) as well as other long-term problems. The severity and the incidence of many complications have improved in the past several years as the intensity of conditioning regimens has diminished and better supportive care and GVHD prevention strategies have been implemented. Transplant clinicians, however, continue to be challenged with problems arising from human leukocyte antigen-mismatched and unrelated donor transplants, expanding transplant indications and age-limit. This review describes the most commonly seen transplant related complications, focusing on their pathogenesis, differential diagnosis and management.
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Kida A, McDonald GB. Gastrointestinal, Hepatobiliary, Pancreatic, and Iron-Related Diseases in Long-Term Survivors of Allogeneic Hematopoietic Cell Transplantation. Semin Hematol 2012; 49:43-58. [DOI: 10.1053/j.seminhematol.2011.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Nieder ML, McDonald GB, Kida A, Hingorani S, Armenian SH, Cooke KR, Pulsipher MA, Baker KS. National Cancer Institute-National Heart, Lung and Blood Institute/pediatric Blood and Marrow Transplant Consortium First International Consensus Conference on late effects after pediatric hematopoietic cell transplantation: long-term organ damage and dysfunction. Biol Blood Marrow Transplant 2011; 17:1573-84. [PMID: 21963877 PMCID: PMC3215762 DOI: 10.1016/j.bbmt.2011.09.013] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Accepted: 09/27/2011] [Indexed: 01/19/2023]
Abstract
Long-term complications after hematopoietic cell transplantation (HCT) have been studied in detail. Although virtually every organ system can be adversely affected after HCT, the underlying pathophysiology of these late effects remain incompletely understood. This article describes our current understanding of the pathophysiology of late effects involving the gastrointestinal, renal, cardiac, and pulmonary systems, and discusses post-HCT metabolic syndrome studies. Underlying diseases, pretransplantation exposures, transplantation conditioning regimens, graft-versus-host disease, and other treatments contribute to these problems. Because organ systems are interdependent, long-term complications with similar pathophysiologic mechanisms often involve multiple organ systems. Current data suggest that post-HCT organ complications result from cellular damage that leads to a cascade of complex events. The interplay between inflammatory processes and dysregulated cellular repair likely contributes to end-organ fibrosis and dysfunction. Although many long-term problems cannot be prevented, appropriate monitoring can enable detection and organ-preserving medical management at earlier stages. Current management strategies are aimed at minimizing symptoms and optimizing function. There remain significant gaps in our knowledge of the pathophysiology of therapy-related organ toxicities disease after HCT. These gaps can be addressed by closely examining disease biology and identifying those patients at greatest risk for adverse outcomes. In addition, strategies are needed for targeted disease prevention and health promotion efforts for individuals deemed at high risk because of their genetic makeup or specific exposure profile.
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Affiliation(s)
| | - George B. McDonald
- University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Aiko Kida
- University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Sangeeta Hingorani
- University of Washington, Seattle Children’s Hospital, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Kenneth R. Cooke
- Case Western Reserve University, Rainbow Babies & Children’s Hospital, Cleveland, OH
| | - Michael A. Pulsipher
- Primary Children’s Medical Center, Division of Hematology/BMT, University of Utah School of Medicine/Huntsman Cancer Institute, Salt Lake City, UT
| | - K. Scott Baker
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
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Notch signaling is a critical regulator of allogeneic CD4+ T-cell responses mediating graft-versus-host disease. Blood 2010; 117:299-308. [PMID: 20870902 DOI: 10.1182/blood-2010-03-271940] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Graft-versus-host disease (GVHD) remains the major barrier to the success of allogeneic hematopoietic stem cell transplantation (HSCT). GVHD is caused by donor T cells that mediate host tissue injury through multiple inflammatory mechanisms. Blockade of individual effector molecules has limited efficacy in controlling GVHD. Here, we report that Notch signaling is a potent regulator of T-cell activation, differentiation, and function during acute GVHD. Inhibition of canonical Notch signaling in donor T cells markedly reduced GVHD severity and mortality in mouse models of allogeneic HSCT. Although Notch-deprived T cells proliferated and expanded in response to alloantigens in vivo, their ability to produce interleukin-2 and inflammatory cytokines was defective, and both CD4(+) and CD8(+) T cells failed to up-regulate selected effector molecules. Notch inhibition decreased the accumulation of alloreactive T cells in the intestine, a key GVHD target organ. However, Notch-deprived alloreactive CD4(+) T cells retained significant cytotoxic potential and antileukemic activity, leading to improved overall survival of the recipients. These results identify Notch as a novel essential regulator of pathogenic CD4(+) T-cell responses during acute GVHD and suggest that Notch signaling in T cells should be investigated as a therapeutic target after allogeneic HSCT.
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Abstract
A spectrum of oncologic treatments including chemotherapy, radiotherapy, and molecular targeted therapies is available to combat cancer. These treatments are associated with adverse effects in several organ systems including the gastrointestinal (GI) tract. The immunocompromised state induced by oncologic therapy is also an important contributing factor underlying GI complications. This review discusses common GI complications that can result from cancer therapy. The pathologic mechanisms underlying each complication and the pharmacology of the agents used to treat these complications are discussed.
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Greinix HT, Loddenkemper C, Pavletic SZ, Holler E, Socié G, Lawitschka A, Halter J, Wolff D. Diagnosis and staging of chronic graft-versus-host disease in the clinical practice. Biol Blood Marrow Transplant 2010; 17:167-75. [PMID: 20691801 DOI: 10.1016/j.bbmt.2010.07.017] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Accepted: 07/19/2010] [Indexed: 12/16/2022]
Abstract
Based on expert opinion and retrospective data the National Institutes of Health (NIH) Consensus Development Project proposed criteria for diagnosis and staging of both overall severity as well as organ severity of chronic graft-versus-host disease (cGVHD) for use in clinical trials. In 2008, representatives of German and Austrian allogeneic hematopoietic stem cell transplant (HSCT) centers established a study group on cGVHD during the annual meeting of the German Working Group on Bone Marrow and Blood Stem Cell Transplantation (DAG-KBT) to intensify a dialog among HSCT physicians, pathologists, and medical consultants focusing on the usefulness of the NIH consensus criteria for patient care in clinical practice and to promote collaborations between HSCT centers as well as different medical specialities involved in HSCT. We first conducted a survey of current practices of diagnosis, staging, and overall grading of cGVHD in daily clinical routine by sending an electronic questionnaire to the heads of the HSCT centers. During 3 meetings in 2009, more representatives of allogeneic HSCT centers were included into the discussion process, resulting in 81% participation representing 88% of all allogeneic HSCT activities in Germany, Austria, and Switzerland. During the third consensus meeting held in Regensburg, Germany, from November 6 to November 7, 2009, important agreements were achieved among participant having a strong impact on care of patients with cGVHD. Areas of disagreement such as distinction between classical NIH cGVHD and overlap syndrome or assignment of liver GVHD after day 100 to acute or chronic category will be further assessed in prospective observational studies among participants in the near future.
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Affiliation(s)
- Hildegard T Greinix
- Department of Internal Medicine I, Bone Marrow Transplantation, Medical University of Vienna, Vienna, Austria.
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Abstract
Chronic graft-versus-host disease (GVHD) is a major complication after allogeneic haematopoietic stem cell transplantation (HSCT). Not only is it the major cause of late mortality in HSCT patients, but it also accounts for significant morbidity. Much of the literature on chronic GVHD has focused on adults. Chronic GVHD is of major importance in children, especially since they have years to live following the complications of chronic GVHD and its therapy. The goal is to review incidence, manifestations, and therapies, especially when applicable to the paediatric population.
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Abstract
Liver problems caused by infection, cholestasis and sinusoidal liver injury in the months following HCT have become less frequent because of preventive and pre-emptive strategies. When patients develop jaundice after transplant, the time to search for treatable causes is early in the course of jaundice, as the risk of mortality rises steeply with small increments of serum bilirubin above normal. Chronic hepatitis C, persistent GVHD, cirrhosis and hepatocellular carcinoma are significant liver problems in the longest-lived survivors of HCT.
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Affiliation(s)
- George B. McDonald
- Gastroenterology/Hepatology Section, Fred Hutchinson Cancer Research Center and the Department of Medicine, University of Washington School of Medicine, Seattle, Washington, U.S.A
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37
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Ali SA, Shah V, McKinnon R, Van Harn M, Janakiraman N. Frequent expression of C4d in hepatic graft-versus-host disease: potential clue for diagnosis and distinguishing acute and chronic form. Transpl Immunol 2010; 23:77-80. [PMID: 20230895 DOI: 10.1016/j.trim.2010.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Revised: 03/01/2010] [Accepted: 03/09/2010] [Indexed: 11/15/2022]
Abstract
BACKGROUND Graft-versus-host disease (GVHD), a common complication of hematopoietic stem cell transplant, is generally regarded to develop through cell-mediated immune response following activation of helper T cells. Since production of antibodies is also mediated by helper T cells, the role of humoral immunity in GVHD is questioned and has not yet been explored in clinical practice. We conducted a pilot study to evaluate the role of antibody production in hepatic H-GVHD and whether it can distinguish acute and chronic forms. RESULTS C4d expression was increased in portal vessels and hepatic sinusoids of patients with histological proven evidence of GVHD 11/16 (P=0.007). Patients classified as chronic GVHD were statistically more likely to have C4d expression in the portal vasculature and liver sinusoids (P=0.011). CONCLUSION Humoral activation seems to play a role in pathophysiology of hepatic, especially chronic GVHD.
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Affiliation(s)
- Sharif A Ali
- Department of Pathology and Laboratory Medicine, Detroit, MI 48202, United States.
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Abstract
Five-year survival rates for childhood cancer now exceed 80% and with the significant progress made by the transplant community in developing less toxic conditioning regimens and in the treatment of posttransplant complications, allo-hematopoietic stem cell transplantation (HSCT) contributes significantly to that population of long-term survivors. In this context, the acute and long-term toxicities of chronic graft-versus-host disease (cGVHD) have an ever-increasing effect on organ function, quality of life, and survival; patients and families who initially felt great relief to be cured from the primary disease, now face the challenge of a chronic debilitating illness for which preventative and treatment strategies are suboptimal. Hence, the development of novel strategies that reduce and or control cGVHD, preserve graft-versus-tumor effects, facilitate engraftment and immune reconstitution, and enhance survival after allo-HSCT represents one of the most significant challenges facing physician-scientists and patients.
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Affiliation(s)
- Kristin Baird
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Building 10, Room 1-3750, 9000 Rockville Pike, MSC 1104, Bethesda, MD 20892-1104, USA.
| | - Kenneth Cooke
- Ohio Eminent Scholar and Leonard C Hanna Professor in Stem Cell and Regenerative Medicine, and Director, Pediatric Blood and Marrow Transplantation Program Director, Multidisciplinary Initiative in Graft-vs-Host Disease, Case Western Reserve University School of Medicine
| | - Kirk R. Schultz
- Director, Childhood Cancer Research Program of BC Children’s Hospital and the Child and Family Research Institute, and Professor of Pediatrics, BC Children’s Hospital
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Socié G, de Latour RP, McDonald GB. Hepatitis C virus and allogeneic stem cell transplantation still matters! Haematologica 2009; 94:170-2. [PMID: 19181791 DOI: 10.3324/haematol.2008.002048] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Roh JH, Han J, Yoo KH, Ahn KM, Kim J. Graft-Versus-Host Disease of the Lung after Allogeneic Hematopoietic Stem Cell Transplantation - A Report of Two Cases -. KOREAN JOURNAL OF PATHOLOGY 2009. [DOI: 10.4132/koreanjpathol.2009.43.4.378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Ji Hyeon Roh
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joungho Han
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keon-Hee Yoo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kang-Mo Ahn
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jihye Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Gastrointestinal complications of oncologic therapy. ACTA ACUST UNITED AC 2008; 5:682-96. [PMID: 18941434 DOI: 10.1038/ncpgasthep1277] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2008] [Accepted: 09/11/2008] [Indexed: 12/19/2022]
Abstract
Gastrointestinal complications are common in patients undergoing various forms of cancer treatment, including chemotherapy, radiation therapy, and molecular-targeted therapies. Many of these complications are life-threatening and require prompt diagnosis and treatment. Complications of oncologic therapy can occur in the esophagus (esophagitis, strictures, bacterial, viral and fungal infections), upper gastrointestinal tract (mucositis, bleeding, nausea and vomiting), colon (diarrhea, graft-versus-host disease, colitis and constipation), liver (drug hepatotoxicity and graft-versus-host disease), and pancreas (pancreatitis). Treatment of the different gastrointestinal complications should be tailored to the individual patient and based on the underlying pathophysiology of the complication.
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Peffault de Latour R, Ribaud P, Robin M, Valla D, Marcellin P, Socié G, Asselah T. Allogeneic hematopoietic cell transplant in HCV-infected patients. J Hepatol 2008; 48:1008-17. [PMID: 18433917 DOI: 10.1016/j.jhep.2008.03.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hepatitis C virus (HCV) is a major cause of liver disease worldwide. After allogeneic Hematopoietic Cell Transplant (HCT), HCV is known to be associated with transient hepatitis in the immediate post-transplant period, and a potential risk factor of veno-occlusive disease (SOS). Very recently, HCV-infected HCT recipients have been shown to be at higher risk of earlier cirrhosis, leading to greater morbidity and mortality. Long-term survivors after HCT are thus at a high risk for HCV-related complications and, as a consequence, the treatment of HCV infection becomes critical. We describe here the potential clinical complications in HCV-infected recipients, in the short, but also the long-term follow-up after HCT. The pathophysiology of liver fibrosis is discussed as well as the present recommended therapy in this particular population.
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Abstract
The liver has a double blood supply and plays a central role in the metabolism of proteins, carbohydrates, and many medications. In addition, it has a role in the induction of immune tolerance and may also be a target for immune-mediated damage. For these reasons, the liver may be involved in many systemic diseases. In this review, we discuss the involvement of the liver in granulomatous, rheumatologic, malignant, and circulatory diseases. An understanding of the wide spectrum of liver involvement in systemic diseases will aid in both diagnosis and treatment of patients with a wide range of medical conditions.
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Yoshida Y, Hirano T, Son G, Iimuro Y, Imado T, Iwasaki T, Fujimoto J. Allogeneic bone marrow transplantation for hepatocellular carcinoma: hepatocyte growth factor suppresses graft-vs.-host disease. Am J Physiol Gastrointest Liver Physiol 2007; 293:G1114-23. [PMID: 17761834 DOI: 10.1152/ajpgi.00026.2007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Allogeneic bone-marrow transplantation (BMT) can induce a powerful graft-vs.-tumor (GVT) effect not only on hematological malignancies but also on solid tumors. However, graft-vs.-host disease (GVHD) is a major complication of allogeneic BMT. We assessed GVT effect on hepatocellular carcinoma (HCC) and the effects of hepatocyte growth factor (HGF) gene transduction on GVHD in HCC transplanted mice. (C57BL/6 x C3H/HeJ)F(1)(B6C3F1, H-2(bxk)) mice were used as recipients and C3H/HeJ(H-2(k)) mice were used as donors. Hepa1-a (a C57L mouse-derived hepatoma cell, H-2(b)) was subcutaneously injected into the recipient mice. Tumor bearing mice were treated in the following ways: group 1, no treatment; group 2, total body irradiation (TBI); group 3, TBI and BMT; group 4, TBI and BMT with empty vector; group 5, TBI and BMT with HGF gene transduction; group 6, TBI and BMT with administration of FK506, a representative immunosuppressive agent. Acute GVHD was assessed by histological examination of the liver, small intestines, and large intestines. Tumor growth was markedly suppressed in mice that received an allogeneic BMT. Donor-derived CD8(+) T cells had infiltrated into the tumor, and cytotoxic CD8(+) T cells against HCC were present. However, among the four groups that received a BMT, this suppressive effect was weaker in group 6 compared with the other three groups (groups 3, 4, and 5). HGF gene transduction improved GVHD while preserving the GVT effects. Allogeneic BMT markedly suppresses the growth of HCC. Simultaneous HGF gene transfer can suppress GVHD while preserving the GVT effect.
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Affiliation(s)
- Yasuhiko Yoshida
- First Dept. of Surgery, Hyogo College of Medicine, Mukogawacho, Nishinomiya, 663, Japan
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45
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Quaglia A, Duarte R, Patch D, Ngianga-Bakwin K, Dhillon AP. Histopathology of graft versus host disease of the liver. Histopathology 2007; 50:727-38. [PMID: 17493237 DOI: 10.1111/j.1365-2559.2007.02679.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS To analyse the histological features of 33 patients (48 biopsy specimens) with a clinicopathological diagnosis of graft vs. host disease of the liver (L-GVHD). RESULTS The time of biopsy post-haematopoietic stem cell transplantation (HSCT) ranged from 22 to 1082 days (median 144 days). Bile duct damage (BDD) was present in all biopsies except one. The bile duct to portal ratio ranged from 0.3 to 1 (median 0.8). Moderate/severe lobular hepatitis was present in 11 biopsies. Endotheliitis was present in four biopsies (8%). The majority of the biopsies showed none [25 (52%)] or mild [17 (35%)] fibrosis. The only significant difference between biopsies earlier ("acute") or later ("chronic" GVHD) than 100 days post-HSCT was the presence of portal inflammation in the "chronic" GVHD group. CONCLUSION BDD is the predominant change in L-GVHD. In about a quarter of biopsies the appearance may be of a lobular hepatitis. L-GVHD is not a fibrogenic process. The significance of separating acute versus chronic L-GVHD based on a cut-off of 100 days post-HSCT is questionable. Further studies are needed to understand the relationships between the mechanisms of BDD, bile duct loss and regeneration.
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Affiliation(s)
- A Quaglia
- Department of Histopathology, Royal Free Hospital, and Institute of Liver Studies, King's College Hospital, Denmark Hill, London, UK
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46
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Carreras E. Risk assessment in haematopoietic stem cell transplantation: The liver as a risk factor. Best Pract Res Clin Haematol 2007; 20:231-46. [PMID: 17448959 DOI: 10.1016/j.beha.2006.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Patients with liver dysfunction have an increased risk of developing early and late complications after haematopoietic stem-cell transplantation (HSCT). That's why it is mandatory to evaluate liver status before transplantation in all cases. This evaluation should allow us to decide whether HSCT can be performed or whether we should adopt measures focused on preventing these complications. The evaluation of the liver in an HSCT candidate requires the collection of information by history-taking, physical examination, liver-function tests and, occasionally, imaging tests and liver biopsy. Additionally, as infection by hepatitis B or C viruses represents the most relevant cause of hepatic dysfunction after HSCT, the serological status of the patient should be carefully evaluated. This chapter tries to analyse and systematise the most important aspects in the patient's evaluation. Finally, as some liver dysfunctions in the stem-cell donor can have a negative impact for the donor during the harvest and/or for the recipient during HSCT, the methodology to evaluate the donors will also be analysed.
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47
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Abstract
Hepatic diseases are common complications of haematopoietic cell transplant. The causes are multiple: myeloablative conditioning regimens may cause sinusoidal injury; acute and chronic graft-versus-host disease lead to damaged hepatocytes and small bile ducts; microcrystalline deposits in the gall bladder can cause biliary symptoms; drug-induced liver injury is common; and the liver may be infected by viruses and fungi during the period of severe immune suppression that follows transplant. Pre-transplant evaluation and prevention of liver injury are often more useful than treatment of deeply jaundiced patients in improving transplant outcomes. This review covers pre-transplant evaluation, common hepatobiliary problems in the six months following transplant, and hepatic problems in long-term survivors.
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Affiliation(s)
- G B McDonald
- Gastroenterology/Hepatology Section, Fred Hutchinson Cancer Research Center, University of Washington School of Medicine, Seattle, WA 98109-1024, USA
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48
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Filipovich AH, Weisdorf D, Pavletic S, Socie G, Wingard JR, Lee SJ, Martin P, Chien J, Przepiorka D, Couriel D, Cowen EW, Dinndorf P, Farrell A, Hartzman R, Henslee-Downey J, Jacobsohn D, McDonald G, Mittleman B, Rizzo JD, Robinson M, Schubert M, Schultz K, Shulman H, Turner M, Vogelsang G, Flowers MED. National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: I. Diagnosis and staging working group report. Biol Blood Marrow Transplant 2006; 11:945-56. [PMID: 16338616 DOI: 10.1016/j.bbmt.2005.09.004] [Citation(s) in RCA: 2768] [Impact Index Per Article: 153.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2005] [Accepted: 09/09/2005] [Indexed: 12/13/2022]
Abstract
This consensus document is intended to serve 3 functions. First, it standardizes the criteria for diagnosis of chronic graft-versus-host disease (GVHD). Second, it proposes a new clinical scoring system (0-3) that describes the extent and severity of chronic GVHD for each organ or site at any given time, taking functional impact into account. Third, it proposes new guidelines for global assessment of chronic GVHD severity that are based on the number of organs or sites involved and the degree of involvement in affected organs (mild, moderate, or severe). Diagnosis of chronic GVHD requires the presence of at least 1 diagnostic clinical sign of chronic GVHD (e.g., poikiloderma or esophageal web) or the presence of at least 1 distinctive manifestation (e.g., keratoconjunctivitis sicca) confirmed by pertinent biopsy or other relevant tests (e.g., Schirmer test) in the same or another organ. Furthermore, other possible diagnoses for clinical symptoms must be excluded. No time limit is set for the diagnosis of chronic GVHD. The Working Group recognized 2 main categories of GVHD, each with 2 subcategories. The acute GVHD category is defined in the absence of diagnostic or distinctive features of chronic GVHD and includes (1) classic acute GVHD occurring within 100 days after transplantation and (2) persistent, recurrent, or late acute GVHD (features of acute GVHD occurring beyond 100 days, often during withdrawal of immune suppression). The broad category of chronic GVHD includes (1) classic chronic GVHD (without features or characteristics of acute GVHD) and (2) an overlap syndrome in which diagnostic or distinctive features of chronic GVHD and acute GVHD appear together. It is currently recommended that systemic therapy be considered for patients who meet criteria for chronic GVHD of moderate to severe global severity.
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Affiliation(s)
- Alexandra H Filipovich
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio 45229, USA.
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McDonald GB. Advances in prevention and treatment of hepatic disorders following hematopoietic cell transplantation. Best Pract Res Clin Haematol 2006; 19:341-52. [PMID: 16516132 DOI: 10.1016/j.beha.2005.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Development of jaundice is an ominous prognostic sign, whether it occurs early or late in the months following hematopoietic cell transplant. In the first weeks after transplant, the dominant causes of liver injury are Sinusoidal Obstruction Syndrome (toxic damage resulting from myeloablative conditioning regimens) and cholangitis lenta (cholestasis of sepsis). Later after transplant, cholestasis is more commonly caused by acute graft-vs.-host disease and drugs. Hepatic infections have become uncommon because of the use of prophylactic anti-fungal and anti-viral drugs. Treatment of severe liver dysfunction is often futile in this setting, but prevention of liver injury is feasible. Hepatic sinusoidal injury can be prevented by avoiding sinusoidal toxins as part of conditioning therapy in patients at high-risk. Cholestatic liver damage can be minimized by prophylactic use of ursodiol and by careful drug monitoring. Anti-microbial drugs will prevent most fungal liver infections and viral hepatitis caused by herpesviruses and hepatitis B virus.
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Affiliation(s)
- George B McDonald
- Gastroenterology/Hepatology Section (D2-1900), Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, Seattle, WA 98109-1024, USA
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Abstract
Acute graft-versus-host disease (GVHD), initiated by the reaction of donor T lymphocytes against nonshared recipient antigens, typically leads to a clinical syndrome characterized by cutaneous eruptions and intestinal and hepatic dysfunction. These three organ systems are considered in the clinical grading of acute GVHD. However, other targets may be involved. With conventional transplant conditioning regimens and in vivo prophylaxis, GVHD becomes clinically manifest within 2 to 4 weeks. With reduced-intensity conditioning, the onset of acute GVHD may be delayed until 2 to 3 months after transplantation. Hyperacute GVHD may occur within a week of transplantation after severely human leukocyte antigen (HLA)-mismatched transplants or transplants without GVHD prophylaxis. There is no reliable laboratory test for acute GVHD, and the diagnosis is based on clinical assessment.
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Affiliation(s)
- H Joachim Deeg
- Fred Hutchinson Cancer Research Center, Seattle WA 98109-1024, USA.
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