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Ercan LD, Durmaz Ö, Kaymakoğlu S, Önal Z, Büyükbabani N, Güllüoğlu M, Alper A, İbiş C, Cantez S, Yavru HA, Oğuz FS, Özden İ. The Consequences of HLA Screening in the Prevention of Graft-Versus-Host Disease in Living Donor Liver Transplantation. Pediatr Transplant 2024; 28:e14846. [PMID: 39177044 DOI: 10.1111/petr.14846] [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: 04/24/2024] [Revised: 07/16/2024] [Accepted: 08/08/2024] [Indexed: 08/24/2024]
Abstract
AIMS To study the effects of routine HLA screening and the policy of avoiding donor-dominant one-way HLA match to prevent graft-versus-host disease (GVHD) after living donor liver transplantation (LDLT). PATIENTS AND METHODS The records of potential living liver donors and recipients who attended our center between 2007 and 2018 were reviewed retrospectively. RESULTS Of the 149 patients who underwent LDLT and survived longer than 3 months, two developed GVHD despite our strict policy. The first patient presented with grade II GVHD limited to the skin. She was treated successfully by briefly discontinuing immunosuppression and switching to everolimus. In the second case, the policy had been relaxed due to the availability of a single donor for ABO-incompatible transplantation without any intervention to decrease anti-A antibody levels (special case: A2 to O). Nevertheless, the patient presented with grade I GVHD limited to skin and was treated successfully by adding oral methylprednisolone to tacrolimus and mycophenolate mofetil. To the best of our information, this is the second reported case who recovered from GVHD after LDLT from a donor, homozygous at HLA A, B and DR and a recipient, heterozygous for all. Sixteen potential donors (1.2% of all candidates) of 14 recipients were disqualified solely on the basis of the HLA results; five of these patients died due to unavailability of another donor. CONCLUSION The results support the policy of avoiding HLA combinations that preclude immune recognition of graft lymphocytes as foreign to decrease the risk of GVHD after LDLT.
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Affiliation(s)
- Leman Damla Ercan
- Department of General Surgery, İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Özlem Durmaz
- Department of Pediatrics (Gastroenterology), İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Sabahattin Kaymakoğlu
- Department of Internal Medicine (Gastroenterology), İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Zerrin Önal
- Department of Pediatrics (Gastroenterology), İstanbul Faculty of Medicine, İstanbul, Turkey
| | | | - Mine Güllüoğlu
- Department of Pathology, İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Aydın Alper
- Department of General Surgery, İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Cem İbiş
- Department of General Surgery, İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Serdar Cantez
- Department of Pediatrics (Gastroenterology), İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Hacer Ayşen Yavru
- Department of Anesthesiology, İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Fatma Savran Oğuz
- Department of Medical Biology, İstanbul Faculty of Medicine, İstanbul, Turkey
| | - İlgin Özden
- Department of General Surgery, İstanbul Faculty of Medicine, İstanbul, Turkey
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2
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Izzo A, Pellegrino RA, Locci G, Cesaretti M. Acute graft versus host disease after liver transplantation: where do we stand? Minerva Surg 2023; 78:537-544. [PMID: 36883938 DOI: 10.23736/s2724-5691.23.09868-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Graft-versus-host disease (GVHD) is a rare complication after liver transplantation (LT), with an estimated incidence rate of 0.5% to 2% and a mortality rate as high as 75%. The classical target organs of GVHD include the intestines, liver, and skin. The damage of these organs is not easy to detect for the clinician as there is no widely accepted clinical or laboratory diagnostic tests; as a result, diagnosis and initiation of therapy are often delayed. Moreover, without prospective clinical trials to reference, evidence guiding therapy is limited. This review summarized the current knowledge, the potential applications and the clinical relevance of GVHD after LT, highlighting novel approaches in grading and management of GVHD.
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Affiliation(s)
- Alessandro Izzo
- Department of HPB and Liver Transplantation, Brotzu Hospital, Cagliari, Italy
| | | | - Giorgia Locci
- Department of Pathology, Brotzu Hospital, Cagliari, Italy
| | - Manuela Cesaretti
- Department of HPB and Liver Transplantation, Brotzu Hospital, Cagliari, Italy -
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3
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Cooper JP, Abkowitz JL. How I diagnose and treat acute graft-versus-host disease after solid organ transplantation. Blood 2023; 141:1136-1146. [PMID: 36395067 DOI: 10.1182/blood.2022015954] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 11/03/2022] [Accepted: 11/07/2022] [Indexed: 11/18/2022] Open
Abstract
Acute graft-versus-host disease (GVHD) is a rare complication after solid organ transplantation (SOT) that carries high mortality. Caused by immunocompetent donor leukocytes within the transplanted organ, which become activated against recipient tissues, GVHD typically develops 2 to 12 weeks after SOT and can affect the skin, gastrointestinal tract, liver, and bone marrow. Signs and symptoms are nonspecific and include a rash, nausea, appetite loss, diarrhea, and cytopenias. Pancytopenia from marrow-directed GVHD is the primary driver of mortality. The diagnosis of GVHD is often delayed but should be confirmed by biopsy of an affected organ. Evidence of donor chimerism in blood or marrow supports the diagnosis. When GVHD is diagnosed we initiate treatment with systemic corticosteroids. At that time, if GVHD only involves skin or oral mucosa we also decrease maintenance immunosuppression levels to allow the recipient to reject the donor immune cells. For GVHD involving the marrow we initiate an allogeneic hematopoietic cell donor search early. In this article, we describe 3 cases of GVHD after SOT, outline our approach to diagnosis and management, and then provide analysis of the 3 instructive cases.
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Affiliation(s)
- Jason P Cooper
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
| | - Janis L Abkowitz
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
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4
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The clinical impact of donor against recipient HLA one way mismatch on the occurrence of graft versus host disease in liver transplantation. Sci Rep 2022; 12:20337. [PMID: 36434131 PMCID: PMC9700759 DOI: 10.1038/s41598-022-24778-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022] Open
Abstract
Graft versus host disease (GVHD) after liver transplantation (LT) is a rare, fatal disease. This study aimed to evaluate the risk factors of GVHD after LT including the human leukocyte antigen (HLA) donor-recipient relationship after LT. LT recipients, who underwent HLA typing together with donors, were included in the study. The donor against recipient (D → R) one-way mismatch of HLA loci was evaluated. HLA relationships, along with basic characteristics, were analyzed as variable factors of GVHD, graft survival, and patient survival. A total of 994 living donor LT (LDLT) and 393 deceased donor LT (DDLT) patients were included. Nine patients had suffered GVHD, four LDLT with D → R one-way at three loci, one LDLT without D → R one-way at three loci, and four DDLT without D → R one-way at three loci. Four (57.1%) of seven LDLT patients, with D → R one-way mismatch at three loci, developed GVHD. D → R one-way mismatch at three loci was related to high GVHD incidence (HR 787, p < 0.001, multivariate). D → R one-way mismatch at three loci was related to graft failure and patient death (HR 9.90, p = 0.020 and HR 12.8, p < 0.001, respectively, multivariate). Only one GVHD without D → R one-way mismatch at three loci, survived despite receiving multiple modalities including tumor necrosis factor-alpha inhibitors. D → R one-way mismatch at three loci was significantly related to GVHD incidence after LT.
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5
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Renganathan KK, Ramamurthy A, Jacob S, Tharigopula A, Vaidya A, Gopashetty M, Khakar A. Acute Graft Versus Host Disease Following Liver Transplantation: Case Report With Review of Current Literature. J Clin Exp Hepatol 2022; 12:1244-1251. [PMID: 35814515 PMCID: PMC9257876 DOI: 10.1016/j.jceh.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 03/26/2022] [Indexed: 12/12/2022] Open
Abstract
Graft verus host disease (GVHD) following Liver transplantation is rare life threatening complication with very high mortality rate around 85%. Due to increased recognition of this condition management approach is rapidly evolving due to newer diagnostic methods and drugs. Etiology, risk factors, pathogenesis, preventive strategies, management approach and newer drugs are discussed. We present our experience of 2 cases from a large cohort of 1052 Liver transplant operations over a decade.
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Key Words
- ATG, Anti thymocyte globulin
- BD, Twice a day
- CMV, Cytomegalovirus
- CODIS, Combined DNA Index System
- DBD, Donation after brain death
- DCLD, Decompensated chronic liver disease
- DNA, Deoxy ribonucleic acid
- EBV, Ebstein bar virus
- G-CSF, Granulocyte colony stimulating factor
- GVHD, Graft versus host disease
- HLA, Human Leukocyte antigen
- HPS, Hepatopulmonary syndrome
- HRS, Hepatorenal syndrome
- IL, Interferon
- IVIG, Intravenous immunoglobulin
- JAK, Janus kinase
- LT, Liver transplantation
- MAD CAM, Mucosal addressin cell adhesion molecule
- MDR, Multi drug resistant
- MELD, Model for end stage liver disease
- NAFLD, Non Alcoholic fatty liver disease
- NASH, Non Alcoholic steatohepatitis
- POD, Post operative day
- QD, quaque die, stands for once a day
- STR-PCR, Single tandem repeat polymerase chain reaction
- chain reaction
- combined DNA index system
- deceased donor liver transplantation
- graft versus host disease
- single tanden repeat polymerase
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Affiliation(s)
- Kirubakaran K. Renganathan
- Consultant Hepatobiliary, Pancreatic Surgery and Liver Transplantation, PSG Institute of Medical Sciences and Research, Peelamedu Coimbatore, India
| | - Anand Ramamurthy
- Senior Consultant, Surgical Gastroenterology and Liver Transplantation, Hindu Mission Hospital, 103 GST Road, Tambaram, Chennai 600045, India
| | - Sheeba Jacob
- Consultant, Division of Pathology, Apollo Hospitals, Greams Lane, Off Greams Road, Chennai-600006 India
| | - Anil Tharigopula
- Consultant, Division of Molecular Pathology, Hindu Mission Hospital, 103 GST Road, Tambaram, Chennai 600045, India
| | - Anil Vaidya
- Consultant Intestinal Transplant Surgeon, Cleveland Clinic Main Campus, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Mahesh Gopashetty
- Consultant Transplant Surgeon, BGS Gleneagles Global Hospital, Uttarahalli Main Road, Kengere, Bengaluru 560060, India
| | - Anand Khakar
- Senior Consultant Surgeon, Liver Transplant, CIMS Hospital, OPD NO 2, East Wing, CIMS Hospital, Science City Road, Panchamrut Bunglows II, Ahmedabad 380060, India
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6
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Cooper JP, Perkins JD, Warner PR, Shingina A, Biggins SW, Abkowitz JL, Reyes JD. Acute Graft-Versus-Host Disease After Orthotopic Liver Transplantation: Predicting This Rare Complication Using Machine Learning. Liver Transpl 2022; 28:407-421. [PMID: 34587357 PMCID: PMC9297869 DOI: 10.1002/lt.26318] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/13/2021] [Accepted: 09/22/2021] [Indexed: 01/13/2023]
Abstract
Acute graft-versus-host disease (GVHD) is a rare complication after orthotopic liver transplantation (OLT) that carries high mortality. We hypothesized that machine-learning algorithms to predict rare events would identify patients at high risk for developing GVHD. To develop a predictive model, we retrospectively evaluated the clinical features of 1938 donor-recipient pairs at the time they underwent OLT at our center; 19 (1.0%) of these recipients developed GVHD. This population was divided into training (70%) and test (30%) sets. A total of 7 machine-learning classification algorithms were built based on the training data set to identify patients at high risk for GVHD. The C5.0, heterogeneous ensemble, and generalized gradient boosting machine (GGBM) algorithms predicted that 21% to 28% of the recipients in the test data set were at high risk for developing GVHD, with an area under the receiver operating characteristic curve (AUROC) of 0.83 to 0.86. The 7 algorithms were then evaluated in a validation data set of 75 more recent donor-recipient pairs who underwent OLT at our center; 2 of these recipients developed GVHD. The logistic regression, heterogeneous ensemble, and GGBM algorithms predicted that 9% to 11% of the validation recipients were at high risk for developing GVHD, with an AUROC of 0.93 to 0.96 that included the 2 recipients who developed GVHD. In conclusion, we present a practical model that can identify patients at high risk for GVHD who may warrant additional monitoring with peripheral blood chimerism testing.
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Affiliation(s)
- Jason P. Cooper
- Division of HematologyDepartment of MedicineUniversity of WashingtonSeattleWA
| | - James D. Perkins
- Division of Transplant SurgeryUniversity of WashingtonSeattleWA,Clinical and Bio‐Analytics Transplant Laboratory in the Department of Surgery at the University of Washington School of MedicineSeattleWA
| | | | - Alexandra Shingina
- Division of GastroenterologyDepartment of MedicineUniversity of WashingtonSeattleWA,Present address:
Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical CenterNashvilleTN
| | - Scott W. Biggins
- Clinical and Bio‐Analytics Transplant Laboratory in the Department of Surgery at the University of Washington School of MedicineSeattleWA,Division of GastroenterologyDepartment of MedicineUniversity of WashingtonSeattleWA
| | - Janis L. Abkowitz
- Division of HematologyDepartment of MedicineUniversity of WashingtonSeattleWA
| | - Jorge D. Reyes
- Division of Transplant SurgeryUniversity of WashingtonSeattleWA,Clinical and Bio‐Analytics Transplant Laboratory in the Department of Surgery at the University of Washington School of MedicineSeattleWA
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7
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Hirata M, Yagi S, Shindo T, Yoshizawa A, Kiguchi G, Kaneshiro M, Yurugi K, Miyachi Y, Iwamura S, Yao S, Uemoto S. Donor-dominant one-way matching of human leukocyte antigen-A/B/DR alleles predicts graft-versus-host disease following living donor liver transplantation. Hepatol Res 2021; 51:135-148. [PMID: 33034106 DOI: 10.1111/hepr.13579] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/31/2020] [Accepted: 09/18/2020] [Indexed: 12/12/2022]
Abstract
AIM Graft-versus-host disease (GVHD) following liver transplantation is rare but fatal. Therefore, it is important to identify possible risk factors before transplantation. Although it has been suggested that donor-dominant one-way human leukocyte antigen (HLA) matching of three loci (HLA-A/B/DR) is associated with the occurrence of GVHD, the precise significance of HLA matching including HLA-C/DQ/DP remains unclear. METHODS We retrospectively analyzed the impact of donor-dominant one-way HLA matching at six HLA loci at the allele level on GVHD using clinical registry data from 1759 cases who underwent living donor liver transplantation between June 1990 and June 2019. We extracted cases with donor-dominant one-way HLA matching at the antigen level and reconfirmed them at the allele level using preserved DNA samples. RESULTS Three of four cases (75%) who developed GVHD showed donor-dominant one-way HLA matching at three HLA-A/B/DR loci. These cases also showed donor-dominant one-way HLA matching at HLA-C/DQ/DP. Three of six cases (50%) with donor-dominant one-way HLA matching at three loci of HLA-A/B/DR developed GVHD. Notably, none of the cases with donor-dominant one-way HLA matching at one or two HLA-A/B/DR loci developed GVHD, irrespective of matching status at HLA-C/DQ/DP. The HLA matching status at the antigen level was revised in 22 of 56 cases, following reconfirmation at the allele level. CONCLUSIONS Pairing of donors and recipients with donor-dominant one-way HLA matching at three HLA-A/B/DR loci should be avoided to prevent GVHD. No impact of HLA-C/DQ/DP on GVHD was identified. For liver transplantation, HLA genotypes should be determined at the allele level.
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Affiliation(s)
- Masaaki Hirata
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shintaro Yagi
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takero Shindo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Atsushi Yoshizawa
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Gozo Kiguchi
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masakatsu Kaneshiro
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kimiko Yurugi
- Department of Transfusion Medicine and Cell Therapy, Kyoto University Hospital, Kyoto, Japan
| | - Yosuke Miyachi
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Sena Iwamura
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Siyuan Yao
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinji Uemoto
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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8
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Superior Outcomes and Reduced Wait Times in Pediatric Recipients of Living Donor Liver Transplantation. Transplant Direct 2019; 5:e430. [PMID: 30882035 PMCID: PMC6411221 DOI: 10.1097/txd.0000000000000865] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 12/21/2018] [Accepted: 12/22/2018] [Indexed: 01/10/2023] Open
Abstract
Background Living donor liver transplantation (LDLT) is increasingly used to bridge the gap between the current supply and demand imbalance for deceased donor organs to provide lifesaving liver transplantation. Methods Outcomes of 135 children who underwent LDLT were compared with 158 recipients of deceased donor liver transplantation (DDLT) at the largest pediatric liver transplant program in Canada. Results Recipients of LDLT were significantly younger than deceased donor recipients (P ≤ 0.001), less likely to require dialysis pretransplant (P < 0.002) and had shorter wait time duration when the primary indication was cholestatic liver disease (P = 0.003). The LDLT donors were either related genetically or emotionally (79%), or unrelated (21%) to the pediatric recipients. One-, 5-, and 10-year patient survival rates were significantly higher in LDLT (97%, 94%, and 94%) compared with DDLT (92%, 87%, and 80%; log-rank P = 0.02) recipients, as were graft survival rates (96%, 93%, and 93% for LDLT versus 89%, 81.4%, and 70%, respectively, for DDLT; log-rank P = 0.001). Medical and surgical complications were not statistically different between groups. Graft failure was higher in recipients of DDLT (odds ratio, 2.60; 95% confidence interval, 1.02, 6.58) than in the LDLT group after adjustment for clinical characteristics and propensity score. Conclusions Living donor liver transplantation provides superior outcomes for children and is an excellent and effective strategy to increase the chances of receiving a liver transplant.
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9
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Minnee RC, Fieuws S, Jochmans I, Aerts R, Sainz Barriga M, Debaveye Y, Maertens J, Vandenberghe P, Laleman W, van der Merwe S, Verslype C, Cassiman D, Ferdinande P, Nevens F, Pirenne J, Monbaliu D. Improved survival after LTx-associated acute GVHD with mAb therapy targeting IL2RAb and soluble TNFAb: Single-center experience and systematic review. Am J Transplant 2018; 18:3007-3020. [PMID: 29734503 DOI: 10.1111/ajt.14923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 04/25/2018] [Accepted: 04/26/2018] [Indexed: 01/25/2023]
Abstract
Acute graft-versus-host disease (GVHD) after liver transplant (LTx) is a rare complication with a high mortality rate. Recently, monoclonal antibody (mAb) treatment, specifically with anti-interleukin 2 receptor antibodies (IL2RAb) and anti-tumor necrosis factor-α antibodies (TNFAb), has gained increasing interest. However, evidence is mostly limited to case reports and the efficacy remains unclear. Here, we describe 5 patients with LTx-associated GVHD from our center and provide the results of our systematic literature review to evaluate the potential therapeutic benefit of IL2RAb/TNFAb treatment. Of the combined population of 155 patients (5 in our center and 150 through systematic search), 24 were given mAb (15.5%)-4 with TNFAb (2.6%) and 17 with IL2RAb (11%) ("mAb group")-and compared with patients who received other treatments (referred to as "no-mAb group"). Two-sided Fisher exact tests revealed a better survival when comparing treatment with mAb versus no-mAb (11/24 vs 27/131; P = .018), TNFAb versus no-mAb (3/4 vs 27/131; P = .034), and IL2RAb versus no-mAb (8/17 vs 27/131; P = .029). This systematic review suggests a beneficial effect of mAb treatment and a promising role for TNFAb and IL2RAb as a first-line strategy to treat LTx-associated acute GVHD.
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Affiliation(s)
- R C Minnee
- Abdominal transplant surgery and transplantation coordination, University Hospitals Leuven, Leuven, Belgium.,Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - S Fieuws
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, KU Leuven-University of Leuven, Leuven, Belgium.,University Hasselt, Hasselt, Belgium
| | - I Jochmans
- Abdominal transplant surgery and transplantation coordination, University Hospitals Leuven, Leuven, Belgium.,Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - R Aerts
- Abdominal transplant surgery and transplantation coordination, University Hospitals Leuven, Leuven, Belgium.,Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - M Sainz Barriga
- Abdominal transplant surgery and transplantation coordination, University Hospitals Leuven, Leuven, Belgium.,Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Y Debaveye
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - J Maertens
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - P Vandenberghe
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium.,Center for Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - W Laleman
- Department of Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - S van der Merwe
- Department of Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - C Verslype
- Department of Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - D Cassiman
- Department of Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - P Ferdinande
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - F Nevens
- Department of Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - J Pirenne
- Abdominal transplant surgery and transplantation coordination, University Hospitals Leuven, Leuven, Belgium.,Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - D Monbaliu
- Abdominal transplant surgery and transplantation coordination, University Hospitals Leuven, Leuven, Belgium.,Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
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10
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Iemura T, Itoh M, Mano C, Oba A, Kawabata N, Horisawa Y, Matsui M, Miyahara Y, Kanda J. Successful engraftment after cord blood transplantation from an HLA-homozygous donor (homo-to-hetero cord blood transplantation) in a primary myelofibrosis patient with broad HLA antibodies. Transfusion 2018; 58:2773-2776. [DOI: 10.1111/trf.14885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 06/12/2018] [Accepted: 06/12/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Tomoki Iemura
- Department of Hematology; Kyoto City Hospital; Kyoto Japan
| | - Mitsuru Itoh
- Department of Hematology; Kyoto City Hospital; Kyoto Japan
| | - Chihiro Mano
- Department of Hematology; Kyoto City Hospital; Kyoto Japan
| | - Akifumi Oba
- Department of Hematology; Kyoto City Hospital; Kyoto Japan
| | | | | | - Masashi Matsui
- Department of Hematology; Kyoto City Hospital; Kyoto Japan
| | | | - Junya Kanda
- Department of Hematology, Graduate School of Medicine; Kyoto University; Kyoto Japan
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11
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Dermatologic manifestations of solid organ transplantation-associated graft-versus-host disease: A systematic review. J Am Acad Dermatol 2017; 78:1097-1101.e1. [PMID: 29288097 DOI: 10.1016/j.jaad.2017.12.050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 12/12/2017] [Accepted: 12/18/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Graft-versus-host-disease (GVHD) after solid organ transplantation (SOT) is extremely rare. OBJECTIVE To investigate the dermatologic manifestations and clinical outcomes of SOT GVHD. METHODS Systematic literature review of SOT GVHD. RESULTS After full-text article review, we included 61 articles, representing 115 patients and 126 transplanted organs. The most commonly transplanted organ was the liver (n = 81). Among 115 patients, 101 (87.8%) developed skin involvement. The eruption appeared an average of 48.3 days (range, 3-243 days) posttransplant and was pruritic in 5 of 101 (4.9%) cases. The eruption was described as morbilliform in 2 patients (1.9%), confluent in 6 (5.9%), and desquamative in 4 (3.9%) cases. In many cases, specific dermatologic descriptions were lacking. The mortality rate was 72.2%. Relative time of death was reported in 23 patients who died during the follow-up period. These patients died an average of 99.2 days (range, 22-270 days) posttransplant, or 50.9 days after the appearance of dermatologic symptoms. Frequent causes of death were sepsis and multiorgan failure. LIMITATIONS Incomplete descriptions of skin findings and potential publication bias resulting in publication of only the most severe cases. CONCLUSIONS GVHD is a potentially fatal condition that can occur after SOT and often presents with a skin rash. We recommend that dermatologists have a low threshold to consider and pursue this diagnosis in the setting of post-SOT skin eruption.
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12
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Shimata K, Sakamoto R, Anan T, Uchida K, Honda M, Kouroki M, Urabe T, Hayashida S, Yamamoto H, Sugawara Y, Inomata Y. Fatal graft-versus-host disease after living-donor liver transplantation from an HLA-DR-mismatched donor. Pediatr Transplant 2017; 21. [PMID: 28834141 DOI: 10.1111/petr.13039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2017] [Indexed: 11/30/2022]
Abstract
Acute GVHD is a rare complication after liver transplantation that has a high mortality rate. We experienced an infant case complicated with acute GVHD. An 8-month-old infant with biliary atresia underwent LDLT with a graft obtained from his mother. Their HLAs showed a donor-dominant one-way match, not at HLA-DR but at HLA-A, HLA-B, and HLA-C (recipient; A 31/33, B 51/54, C 1/14, DR 9/11, donor; A 31/-, B 51/-, C 14/-, DR 8/11). The patient exhibited a high fever, skin rash, and diarrhea, and was diagnosed with acute GVHD based on the blood chimerism test. Despite immunosuppression treatment with prednisolone and tacrolimus, plasma exchange, blood transfusion including cord blood transplantation, and antibiotics, the child died on postoperative day 126. Donor-dominant one-way matching at HLA class 1 can be a high-risk factor for acute GVHD despite HLA class 2 mismatching.
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Affiliation(s)
- Keita Shimata
- Department of Transplantation and Pediatric Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Rieko Sakamoto
- Department of Pediatrics, Kumamoto University Hospital, Kumamoto, Japan
| | - Tadashi Anan
- Department of Pediatrics, Kumamoto University Hospital, Kumamoto, Japan
| | - Koushi Uchida
- Department of Transplantation and Pediatric Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Masaki Honda
- Department of Transplantation and Pediatric Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Masahiko Kouroki
- Department of Pediatrics, Kumamoto University Hospital, Kumamoto, Japan
| | - Tomonari Urabe
- Department of Pediatrics, Kumamoto University Hospital, Kumamoto, Japan
| | - Shintaro Hayashida
- Department of Transplantation and Pediatric Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Hidekazu Yamamoto
- Department of Transplantation and Pediatric Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Yasuhiko Sugawara
- Department of Transplantation and Pediatric Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Yukihiro Inomata
- Department of Transplantation and Pediatric Surgery, Kumamoto University Hospital, Kumamoto, Japan
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Zhi X, Xue F, Chen W, Liang C, Liu H, Ma T, Xia X, Hu L, Bai X, Liang T. OSI-027 modulates acute graft-versus-host disease after liver transplantation in a rat model. Liver Transpl 2017; 23:1186-1198. [PMID: 28590550 DOI: 10.1002/lt.24797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 05/01/2017] [Accepted: 05/29/2017] [Indexed: 01/13/2023]
Abstract
Despite its rarity (1%-2%), acute graft-versus-host disease after liver transplantation (LT-aGVHD) has a high mortality rate (85%). A gradual decrease in regulatory T cells (Tregs) correlates with disease progression in a rat LT-GVHD model, and treatments which increase Tregs exert therapeutic effects on LT-aGVHD. In this study, LT-aGVHD model rats were treated with rapamycin (RAPA), OSI-027, or an equal quantity of vehicle. Rats treated with OSI-027 survived longer (>100 days) than those in the RAPA (70 ± 8 days) or control (24 ± 3 days) groups. Flow cytometric analysis showed that the Treg ratios in peripheral blood mononuclear cells in the OSI-027 group were higher than those in the RAPA or control groups. The proportions of donor-derived lymphocytes in the OSI-027 group were lower than those in the RAPA or control groups. Hematoxylin-eosin staining of skin tissue demonstrated less severe lymphocyte infiltration in the OSI-027 group than that in the RAPA or control groups. In vitro, OSI-027 induced differentiation of CD4+ CD25- T cells into CD4+ CD25+ forkhead box P3+ Tregs. Furthermore, injection of OSI-027-induced donor-derived CD4+ CD25+ T cells into the peripheral blood of LT-aGVHD model rats prevented LT-aGVHD. Thus, OSI-027 is implicated as a novel method for the treatment of LT-aGVHD. Liver Transplantation 23 1186-1198 2017 AASLD.
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Affiliation(s)
- Xiao Zhi
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou, People's Republic of China
| | - Fei Xue
- Department of Hepatobiliary and Pancreatic Surgery, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, People's Republic of China
| | - Wei Chen
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou, People's Republic of China
| | - Chao Liang
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou, People's Republic of China
| | - Hao Liu
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou, People's Republic of China
| | - Tao Ma
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou, People's Republic of China
| | - Xuefeng Xia
- Deparment of General Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, People's Republic of China
| | - Liqiang Hu
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou, People's Republic of China
| | - Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou, People's Republic of China
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou, People's Republic of China.,Key Laboratory of Cancer Prevention and Intervention, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
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14
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Graft Versus Host Disease After Liver Transplantation in Adults: A Case series, Review of Literature, and an Approach to Management. Transplantation 2017; 100:2661-2670. [PMID: 27495762 DOI: 10.1097/tp.0000000000001406] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Graft-versus-host-disease (GVHD) after liver transplantation (LT) is a deadly complication with very limited data on risk factors, diagnosis and management. We report a case series and a comprehensive review of the literature. METHODS Data were systematically extracted from reports of GVHD after LT, and from the United Network for Organ Sharing database. Group comparisons were performed. RESULTS One hundred fifty-six adult patients with GVHD after LT have been reported. Median time to GVHD onset was 28 days. Clinical features were skin rash (92%), pancytopenia (78%), and diarrhea (65%). Six-month mortality with GVHD after LT was 73%. Sepsis was the most common cause of death (60%). Enterobacter bacteremia, invasive aspergillosis, and disseminated Candida infections were frequently reported. Recipient age over 50 years is a risk factor for GVHD after LT. Hepatocellular carcinoma was overrepresented, whereas chronic hepatitis C was underrepresented, in reported United States GVHD cases relative to all United Network for Organ Sharing database LT cases. Mortality rate with treatment of GVHD after LT was 84% with high-dose steroids alone, 75% to 100% with regimens using dose increases of calcineurin inhibitors, and 55% with IL-2 antagonists. Mortality was 25% in small case series using the CD2-blocker alefacept or TNF-α antagonists. CONCLUSIONS Age older than 50 years and hepatocellular carcinoma appear to be risk factors for GVHD. Hepatitis C may be protective. High-dose steroids and calcineurin inhibitors are ineffective in the treatment of GVHD after LT. CD2-blockers and TNF-α antagonists appear promising. We propose a diagnostic algorithm to assist clinicians in managing adults with GVHD after LT.
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15
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Yu YD, Kim DS, Ha N, Jung SW, Han JH, Kim JY, Park SH, Cho YJ. Fatal Graft-Versus-Host Disease Following Adult-To-Adult Living Donor Liver Transplantation From an HLA Nonhomozygous Donor. Prog Transplant 2016; 26:394-396. [PMID: 27555077 DOI: 10.1177/1526924816664087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The use of a human leukocyte antigen (HLA) homozygous donor to a haploidentical recipient is a well-documented cause of transfusion-associated graft-versus-host disease (GVHD). Several authors have reported that use of a graft from an HLA-homozygous donor with 1-way donor-recipient HLA matching led to an extremely high risk of developing GVHD in LDLT. We have experienced a fatal case of acute GVHD following adult-to-adult LDLT from a donor who was heterozygous at a single HLA locus. A 53-year-old female underwent LDLT for chronic hepatitis B and recurrent hepatocellular carcinoma. The donor was her 23-year-old son. The HLA phenotype of the donor was not homozygous (A24, -; B54, -; DR4, 9) and revealed one-way donor-dominant HLA matching at two loci with the recipient (A2, 24; B48, 54; DR4, 12). On the fortieth postoperative day, the patient showed erythematous skin lesions. Skin biopsy revealed typical findings of GVHD. Donor-derived chimerism was demonstrated by performing fluorescent in situ hybridization (FISH) using the recipient's skin tissue. As the clinical course deteriorated, etanercept was started in addition to broad-spectrum antibiotics but there was no improvement. As multi-organ failure progressed, the patient succumbed to death on the 54th postoperative day, which was 2 weeks after onset of GVHD. The prevention of GVHD is more important since the results of treatment have been disappointing. We have experienced a fatal case of acute GVHD following adult-to-adult LDLT from a HLA non-homozygous donor. HLA heterozygosity at a single locus does not preclude the possibility of developing GVHD following adult-to-adult LDLT.
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Affiliation(s)
- Young-Dong Yu
- 1 Division of HBP surgery and Liver transplantation, Department of Surgery, Korea University Medical Center, Korea University Medical College, Seoul, Korea
| | - Dong-Sik Kim
- 1 Division of HBP surgery and Liver transplantation, Department of Surgery, Korea University Medical Center, Korea University Medical College, Seoul, Korea
| | - Neul Ha
- 1 Division of HBP surgery and Liver transplantation, Department of Surgery, Korea University Medical Center, Korea University Medical College, Seoul, Korea
| | - Sung-Won Jung
- 1 Division of HBP surgery and Liver transplantation, Department of Surgery, Korea University Medical Center, Korea University Medical College, Seoul, Korea
| | - Jae-Hyun Han
- 1 Division of HBP surgery and Liver transplantation, Department of Surgery, Korea University Medical Center, Korea University Medical College, Seoul, Korea
| | - Joo-Young Kim
- 2 Department of Pathology, Korea University Medical Center, Seoul, Korea
| | - Sung-Hwan Park
- 3 Department of Forensic Medicine, Korea University Medical Center, Seoul, Korea
| | - Yun-Jung Cho
- 4 Department of Laboratory Medicine, Korea University Medical Center, Seoul, Korea
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16
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Rai V, Dietz NE, Agrawal DK. Immunological basis for treatment of graft versus host disease after liver transplant. Expert Rev Clin Immunol 2016; 12:583-93. [PMID: 26795873 DOI: 10.1586/1744666x.2016.1145056] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Graft versus host disease (GVHD) after liver transplant, although a rare disease, has a very high mortality rate. GVHD occurs due to immunoreactions caused by donor T lymphocytes and host cell surface antigens resulting in proliferation and clonal expansion of T lymphocyte. Migration of effector cells, including macrophages, NK cells and cytotoxic T lymphocyte, to the target organs such as skin, intestine and bone marrow results in skin rashes, diarrhea and bone marrow depression. GVHD is diagnosed by clinical symptoms, histopathological findings and by the presence of chimerism. The delayed diagnosis, opportunistic infections and lack of definitive treatment of post orthotopic liver transplant (OLT)-GVHD results in sepsis and multi-organ failure leading to very low survival rates. In this review, we have focused on early diagnosis and critically discuss novel treatment modalities to decrease the incidence of GVHD.
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Affiliation(s)
- Vikrant Rai
- a Department of Clinical and Translational Science , Creighton University School of Medicine , Omaha , NE , USA
| | - Nicholas Edward Dietz
- b Department of Pathology , Creighton University School of Medicine , Omaha , NE , USA
| | - Devendra K Agrawal
- a Department of Clinical and Translational Science , Creighton University School of Medicine , Omaha , NE , USA
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17
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Elfeki MA, Genco PV, Pungpapong S, Nakhleh RE, Nguyen JH, Harnois DM. Abatacept use in graft-versus-host disease after orthotopic liver transplantation: a case report. Transplant Proc 2015; 46:2422-5. [PMID: 25242798 DOI: 10.1016/j.transproceed.2014.06.061] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 06/30/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND Graft-versus-host disease (GVHD) is a rare, serious, fatal disease that occurs after orthotopic liver transplantation (OLT). CASE REPORT We treated a 60-year-old man who underwent OLT owing to familial amyloidosis. The patient developed fever on postoperative day 16. The fever was persistent and did not respond to antibiotic therapy. Cultures and radiologic studies were done and excluded infection as a potential cause. On postoperative day 26, a skin rash appeared on his chest, accompanied by diarrhea and persistent fever. The rash spread all over the trunk, neck, and arms, but spared the palms of his hands and soles of his feet. In the meantime, his blood cell count revealed pancytopenia. Skin biopsy was done and showed interface lymphocytic infiltrate that are largely centered on the dermal-epidermal junction, is consistent with GVHD (this pattern of rash distribution is unique and different from the rash of GVHD after hematopoietic stem cell transplant, which is confined to palms of the hands and soles of the feet; Fig 1). The diagnosis was confirmed by colonoscopy and multiple forceps biopsies, which revealed extensive crypt loss. After hematology consultation, the patient was treated by withdrawal of all immunosuppressive therapy coupled with abatacept infusion. Abatacept is a chimeric protein that inhibits T-lymphocytes and is approved by the US Food and Drug Administration for the treatment of rheumatoid arthritis. Interestingly, after second dose of abatacept the patient showed marked clinical and laboratory improvement. The patient was discharged after 47 days in a stable condition. CONCLUSION Because of the lack of a consensus for treatment of these patients, we report our experience with a male patient who had post-OLT GVHD and showed a marked improvement in response to abatacept.
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Affiliation(s)
- M A Elfeki
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, Florida
| | - P V Genco
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, Florida
| | - S Pungpapong
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, Florida
| | - R E Nakhleh
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, Florida
| | - J H Nguyen
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, Florida
| | - D M Harnois
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, Florida.
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18
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Elfeki MA, Pungpapong S, Genco PV, Nakhleh RE, Nguyen JH, Harnois DM. Graft-versus-host disease after orthotopic liver transplantation: multivariate analysis of risk factors. Clin Transplant 2015; 29:1063-6. [PMID: 26358521 DOI: 10.1111/ctr.12627] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2015] [Indexed: 11/26/2022]
Abstract
Graft-versus-host disease (GVHD) is a rare, fatal complication following orthotopic liver transplantation (OLT). To date, several risk factors have been proposed, but reports on these factors have been inconclusive. This is a retrospective, case-control study of prospectively collected data from 2775 OLTs performed at our institution. Eight cases of GVHD after OLT were diagnosed on the basis of the patient's clinical characteristics, and the findings were confirmed with skin and colonic biopsies. Each case was matched to three controls based on the diagnosis of liver disease, recipient's age, and blood group. Univariate and multivariate analyses were performed to identify risk factors associated with the development of GVHD after OLT. The univariate and multivariate analyses identified two main risk factors associated with development of GVHD in OLT recipients, a difference between recipient and donor age of >20 yr, and any human leukocyte antigen class I matches. Taking these two risk factors into consideration while matching prospective donors and recipients may reduce further incidence of GVHD in OLT patients. However, further studies are recommended to validate these findings.
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Affiliation(s)
- Mohamed A Elfeki
- Department of Transplant Medicine, Mayo Clinic, Jacksonville, FL, USA.,Department of Tropical Medicine and Hepatology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | - Petrina V Genco
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL, USA
| | - Raouf E Nakhleh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL, USA
| | - Justin H Nguyen
- Division of Transplant Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Denise M Harnois
- Department of Transplant Medicine, Mayo Clinic, Jacksonville, FL, USA
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19
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Cheung CYM, Leung AYH, Chan SC, Trendell-Smith NJ, So CC, Kwong YL. Fatal graft-versus-host disease after unrelated cadaveric liver transplantation due to donor/recipient human leucocyte antigen matching. Intern Med J 2015; 44:425-6. [PMID: 24754694 DOI: 10.1111/imj.12389] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 02/03/2014] [Indexed: 11/28/2022]
Affiliation(s)
- C Y M Cheung
- Department of Medicine, Queen Mary Hospital, Hong Kong
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20
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Acute graft-versus-host disease following simultaneous pancreas-kidney transplantation: report of a case. Surg Today 2014; 45:1567-71. [DOI: 10.1007/s00595-014-1069-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 10/05/2014] [Indexed: 12/13/2022]
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21
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Jung BH, Hwang S, Ha TY, Song GW, Jung DH, Kim KH, Ahn CS, Moon DB, Park GC, Kang SH, Yoon YI, Lee SG. Assessment of right liver graft perfusion effectiveness between one and two-catheter infusion methods. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2014; 18:43-7. [PMID: 26155247 PMCID: PMC4492314 DOI: 10.14701/kjhbps.2014.18.2.43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 05/15/2014] [Accepted: 05/18/2014] [Indexed: 11/18/2022]
Abstract
Backgrounds/Aims Conventional graft perfusion method using one small-caliber catheter takes a relatively long time for right liver graft perfusion, thus some modification is needed. In this study, we intended to assess the effectiveness of right liver graft perfusion methods through comparison of different infusion catheters. Methods The study consisted of two parts including one bench experiment to obtain data of hydraulic infusion and one clinical trial of 40 cases on graft perfusion with one- versus two-catheter infusion methods. These two graft infusion methods were compared in terms of the perfusion time and washing-out efficiency. Results At bench experiment, the infusion flow rate and infusion pressure were 3.3 ml/sec and 1.9 cmH20 in one blood transfusion catheter group, and 11.7 ml/sec and 3.1 cmH20 in single transurethral resection of prostate irrigation catheter group, and 6.6 ml/sec and 2.0 cmH20 in two blood transfusion catheters group, respectively. In clinical trial with 40 right liver grafts, two-catheter group had a shorter graft portal perfusion time for the first 2 L of histidine-tryptophan-ketoglutarate (HTK) solution than the conventional one-catheter group (375±25 seconds vs. 662±34 seconds; p=0.001) and a lower rate of incomplete blood washing-out after the initial 2 L portal perfusion (40% vs. 85%; p=0.03). Conclusions The two-catheter infusion method appears to be more effective than the conventional one-catheter infusion method for right liver graft perfusion at the back table. Large size of right liver grafts seems to be its good indication.
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Affiliation(s)
- Bo-Hyun Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Hwa Kang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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22
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Schulman JM, Yoon C, Schwarz J, Vagefi PA, Mully TW, Shinkai K. Absence of peripheral blood chimerism in graft-vs-host disease following orthotopic liver transplantation: case report and review of the literature. Int J Dermatol 2013; 53:e492-8. [PMID: 24372059 DOI: 10.1111/ijd.12149] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Graft-vs-host disease (GVHD) is a rare and often fatal complication of orthotopic liver transplantation (OLT). The skin is frequently involved early in disease progression, but clinical and histopathological features may be nonspecific, presenting a diagnostic challenge. While the detection of peripheral blood chimerism has been proposed as a diagnostic criterion for post-OLT GVHD, it is not known whether peripheral blood chimerism is an absolute requirement for the diagnosis. MATERIALS AND METHODS We report a case of a 57-year-old man who developed post-OLT GVHD with cutaneous, enteric, and bone marrow involvement. We also review the epidemiology, pathogenesis, clinical presentation, histopathology, molecular diagnostic techniques, and treatment of GVHD following liver transplantation. RESULTS In our patient, analysis of the peripheral blood by short-tandem repeat polymerase chain reaction did not detect circulating donor lymphocytes. Donor lymphocytes were detected in the buccal mucosa, however, confirming the diagnosis. A review of chimerism patterns in 63 previously published cases of post-OLT GVHD reveals that this is the first reported case in which chimerism was absent in the peripheral blood but present in another site. CONCLUSIONS Peripheral blood chimerism may be absent in cases of post-OLT GVHD. A combination of clinical, histopathological, and molecular features is therefore required to make this challenging diagnosis.
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Affiliation(s)
- Joshua M Schulman
- Department of Dermatology, University of California, San Francisco, CA, USA
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23
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Reddy MS, Varghese J, Venkataraman J, Rela M. Matching donor to recipient in liver transplantation: Relevance in clinical practice. World J Hepatol 2013; 5:603-611. [PMID: 24303088 PMCID: PMC3847943 DOI: 10.4254/wjh.v5.i11.603] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 10/23/2013] [Accepted: 11/05/2013] [Indexed: 02/06/2023] Open
Abstract
Achieving optimum outcomes after liver transplantation requires an understanding of the interaction between donor, graft and recipient factors. Within the cohort of patients waiting for a transplant, better matching of the donor organ to the recipient will improve transplant outcomes and benefit the overall waiting list by minimizing graft failure and need for re-transplantation. A PubMed search was conducted to identify published literature investigating the effects of donor factors such as age, gender, ethnicity, viral serology; graft factors such as size and quality, recipient factors such as age, size, gender and transplant factors such as major or minor blood group incompatibility and immunological factors. We also report technical and therapeutic modifications that can be used to manage donor-recipient mismatch identified from literature and the authors’ clinical experience. Multiple donor and recipient factors impact graft survival after liver transplantation. Appropriate matching based on donor-organ-recipient variables, modification of surgical technique and innovative peri-transplant strategies can increase the donor pool by utilizing grafts from marginal donors that are traditionally turned down.
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24
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Lee HJ, Lee SM, Kim BC, Chu CW, Yang KH, Ryu JH, Moon KM, Choi KU, Kim HH. A Case of Acute Graft versus Host Disease after Liver Transplantation. KOREAN JOURNAL OF TRANSPLANTATION 2013. [DOI: 10.4285/jkstn.2013.27.1.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Hyun Ji Lee
- Department of Laboratory Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Sun Min Lee
- Department of Laboratory Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Byung Chang Kim
- Department of Laboratory Medicine, Maryknoll Medical Center, Busan, Korea
| | - Chong Woo Chu
- Department of Surgery, Pusan National University School of Medicine, Busan, Korea
| | - Kwang Ho Yang
- Department of Surgery, Pusan National University School of Medicine, Busan, Korea
| | - Je Ho Ryu
- Department of Surgery, Pusan National University School of Medicine, Busan, Korea
| | - Ki Myung Moon
- Department of Surgery, Pusan National University School of Medicine, Busan, Korea
| | - Kyung-Un Choi
- Department of Pathology, Pusan National University School of Medicine, Busan, Korea
| | - Hyung Hoi Kim
- Department of Laboratory Medicine, Pusan National University School of Medicine, Busan, Korea
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25
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Uchiyama H, Kayashima H, Matono R, Shirabe K, Yoshizumi T, Ikegami T, Soejima Y, Matsuura T, Taguchi T, Maehara Y. Relevance of HLA compatibility in living donor liver transplantation: the double-edged sword associated with the patient outcome. Clin Transplant 2013; 26:E522-9. [PMID: 23061761 DOI: 10.1111/ctr.12019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
HLA compatibility in living donor liver transplantation (LDLT) seems relevant to the acceptability of graft livers because LDLT recipients often share most or some part of HLAs with the respective donors. This study retrospectively investigated whether HLA compatibility affected the outcome of LDLT. Three hundred ninety LDLTs were performed in this hospital, and 346 pairs of HLAs (HLA-A, B, DR) were retrieved from the medical record between October 1996 and March 2011. The dates of the deaths were censored when a recipient apparently died of or was retransplanted by other causes than graft failure because of host-versus-graft (HVG) response to purely analyze the outcomes of LDLT in view of HVG response. The relationship between HLA compatibility and graft-versus-host disease (GVHD) was also analyzed. No recipients with recipient-against-donor HLA mismatch (R→D MM) 0 experienced graft failure by HVG response. On the other hand, three of five recipients with "R→D MM 0" together with "donor-against-recipient MM 3" died of fatal GVHD. HLA compatibility in LDLT not only affected the long-term acceptance of graft livers but also the risk of fatal GVHD.
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Affiliation(s)
- Hideaki Uchiyama
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Akbulut S, Yilmaz M, Yilmaz S. Graft-versus-host disease after liver transplantation: A comprehensive literature review. World J Gastroenterol 2012; 18:5240-8. [PMID: 23066319 PMCID: PMC3468857 DOI: 10.3748/wjg.v18.i37.5240] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Revised: 06/11/2012] [Accepted: 06/28/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the factors affecting mortality in patients who developed graft-versus-host disease (GvHD) after liver transplantation (LT).
METHODS: We performed a review of studies of GvHD following LT published in the English literature and accessed the PubMed, Medline, EBSCO, EMBASE, and Google Scholar databases. Using relevant search phrases, 88 articles were identified. Of these, 61 articles containing most of the study parameters were considered eligible for the study. Risk factors were first examined using a univariate Kaplan-Meier model, and variables with a significant association (P < 0.05) were then subjected to multivariate analyses using a Cox proportional-hazards model.
RESULTS: The 61 articles reported 87 patients, 58 male and 29 female, mean age, 40.4 ± 15.5 years (range: 8 mo to 74 years), who met the inclusion criteria for the present study. Deaths occurred in 59 (67.8%) patients, whereas 28 (32.2%) survived after a mean follow-up period of 280.8 ± 316.2 d (range: 27-2285 d). Among the most frequent symptoms were rash (94.2%), fever (66.6%), diarrhea (54%), and pancytopenia (54%). The average time period between LT and first symptom onset was 60.6 ± 190.1 d (range: 2-1865 d). The Kaplan-Meier analysis revealed that pancytopenia (42.8% vs 59.3%, P = 0.03), diarrhea (39.2% vs 61.0%, P = 0.04), age difference between the recipient and the donor (14.6 ± 3.1 years vs 22.6 ± 2.7 years, P < 0.0001), and time from first symptom occurrence to diagnosis or treatment (13.3 ± 2.6 mo vs 15.0 ± 2.3 mo, P < 0.0001) were significant factors affecting mortality, whereas age, sex, presence of rash and fever, use of immunosuppressive agents, acute rejection before GvHD, etiological causes, time of onset, and donor type were not associated with mortality risk. The Cox proportional-hazards model, determined that an age difference between the recipient and donor was an independent risk factor (P = 0.03; hazard ratio, 7.395, 95% confidence interval, 1.2-46.7).
CONCLUSION: This study showed that an age difference between the recipient and donor is an independent risk factor for mortality in patients who develop GvHD after LT.
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Rogulj IM, Deeg J, Lee SJ. Acute graft versus host disease after orthotopic liver transplantation. J Hematol Oncol 2012; 5:50. [PMID: 22889203 PMCID: PMC3445845 DOI: 10.1186/1756-8722-5-50] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 07/27/2012] [Indexed: 11/25/2022] Open
Abstract
Graft versus host disease (GVHD) is an uncommon complication after orthotopic liver transplantation (OLT) with an incidence of 0.1–2%, but an 80–100% mortality rate. Patients can present with skin rashes, diarrhea, and bone marrow aplasia between two to eight weeks after OLT. Diagnosis of GVHD is made based on clinical and histologic evidence, supported by chimerism studies showing donor HLA alleles in the recipient bone marrow or blood. Several therapeutic approaches have been used for the management of GVHD after OLT including increased immunosuppression, decreased immunosuppression, and cellular therapies. However, success rates have been low, and new approaches are needed.
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Affiliation(s)
- Inga Mandac Rogulj
- University of Zagreb School of Medicine, University Hospital Merkur, Zagreb, Croatia
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28
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Xia X, Chen W, Ma T, Xu G, Liu H, Liang C, Bai X, Zhang Y, He Y, Liang T. Mesenchymal stem cells administered after liver transplantation prevent acute graft-versus-host disease in rats. Liver Transpl 2012; 18:696-706. [PMID: 22344929 DOI: 10.1002/lt.23414] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Acute graft-versus-host disease is a serious and life-threatening complication of liver transplantation (LT) that occurs in 1% to 2% of liver allograft recipients. It is associated with a high mortality rate, and effective therapies are lacking. In our established rat model, a relative decrease in regulatory T cells (Tregs) was previously shown to be associated with acute graft-versus-host disease after liver transplantation (LT-aGVHD). Mesenchymal stem cells (MSCs) have been used to treat graft-versus-host disease after allogeneic hematopoietic stem cell transplantation, and they have been shown to induce Tregs, which have immunomodulatory effects. In this study, when a treatment with donor- or recipient-derived MSCs was administered from day 8 to day 14 after the typical symptoms of LT-aGVHD started, the recipients were not cured, and their survival time was not prolonged. However, when MSCs of different origins were administered from day 0 to day 6 after LT, the recipients survived significantly longer than the control group, and the surviving MSC-treated rats did not show typical LT-aGVHD symptoms. In vivo tracings of carboxyfluorescein diacetate succinimidyl ester-stained MSCs did not show significant accumulations in the target organs after administration. Flow cytometry analysis showed that the Treg ratios in peripheral blood were more higher for the MSC-treated groups versus the control group. More immunohistochemically stained forkhead box P3-positive cells were also found in the intestines of the MSC-treated groups versus the control group. Further investigations of the function of MSCs showed that they could increase the Treg ratio in a mixed lymphocyte reaction (MLR) and lead to a greater reduction in MLR proliferation in vitro. In conclusion, the post-LT administration of MSCs of either donor or recipient origin could prevent the onset of LT-aGVHD in our rat model.
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Affiliation(s)
- Xuefeng Xia
- Department of Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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29
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Yuksekkaya HA, Arikan C, Tumgor G, Aksoylar S, Kilic M, Aydogdu S. Late-onset graft-versus-host disease after pediatric living-related liver transplantation for Langerhans cell histiocytosis. Pediatr Transplant 2011; 15:E105-9. [PMID: 21884342 DOI: 10.1111/j.1399-3046.2008.00899.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
GVHD is the most common and well-known cause of morbidity and mortality following allogeneic BM transplantation. The GVHD following OLT is an uncommon complication but has a high mortality and poses a major diagnostic and therapeutic challenge. We herein discussed a 12-month-old girl with multi-system LCH, who developed end-stage liver disease despite intensive chemotherapy. She underwent ABO-compatible liver transplantation at 28 months while in remission from LCH. The donor was her 26-yr-old father. Post-operative course was uneventful. The GVHD manifested with skin rash and BM suppression on post-transplant day 94 and confirmed by both microchimerism and skin biopsy. Prednisolone, basiliximab, and ATG were administered immediately but the bone marrow suppression was not improved and the patient died because of Candida sepsis at six-month post-transplant. GVHD after OLT should be keep in mind in patients with rash and BM suppression after liver transplantation. In LDLT, a patient who carries risk factors should investigated for optimal HLA matching.
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Affiliation(s)
- Hasan Ali Yuksekkaya
- Department of Pediatric Gastroenterology, Ege University School of Medicine, Izmir, Turkey
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30
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Xue F, Chen W, Bai XL, Xu GD, Liang L, Liang TB. Correlation of Chimerism with Acute Graft-versus-Host Disease in Rats following Liver Transplantation. Int J Hepatol 2011; 2011:947150. [PMID: 21994878 PMCID: PMC3170856 DOI: 10.4061/2011/947150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Accepted: 03/05/2011] [Indexed: 12/04/2022] Open
Abstract
The accurate diagnosis of acute graft-versus-host disease following liver transplantation (LTx-aGVHD) has been hampered. Chimerism appears in the majority of recipients after LT and its significance in the diagnosis of LTx-aGVHD has not been clearly established. To demonstrate the significance of chimerism on the diagnosis of LTx-aGVHD, we compared the change of chimerism in syngeneic LT recipients, semiallogeneic LT recipients, and LTx-aGVHD induced recipients. Chimerism in PBMCs following sex-mismatched LT was identified by real-time PCR based on a rat Y-chromosome-specific primer. All recipients in semiallogeneic group grew in a normal pattern. However, when 4 × 10(8) donor splenocytes were transferred simultaneously during LT, the morbidity of lethal aGVHD was 100%. The chimerism appeared slightly higher in the semiallogeneic group than in the syngeneic LT group, but the difference was not significant. However, when the recipients developed lethal aGVHD after LT, chimerism in the PBMCs increased progressively, and even at an early time, a significant increase in chimerism was observed. In conclusion, high level chimerism correlated well with LTx-aGVHD, and detection of chimerism soon after transplantation may be of value in the diagnosis of LTx-aGVHD prior to the onset of symptoms.
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Affiliation(s)
- Fei Xue
- Department of Hepatobiliary and Pancreatic Surgery, Key Laboratory of Combined Multi-Organ Transplantation of Ministry of Public Health, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China,Department of Hepatobiliary and Pancreatic Surgery, Organ Transplantation Center, Henan Province People's Hospital, Zhengzhou 450003, Henan Province, China
| | - Wei Chen
- Department of Hepatobiliary and Pancreatic Surgery, Key Laboratory of Combined Multi-Organ Transplantation of Ministry of Public Health, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China
| | - Xue-Li Bai
- Department of Hepatobiliary and Pancreatic Surgery, Key Laboratory of Combined Multi-Organ Transplantation of Ministry of Public Health, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China
| | - Guo-Dong Xu
- Department of Hepatobiliary and Pancreatic Surgery, Key Laboratory of Combined Multi-Organ Transplantation of Ministry of Public Health, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China
| | - Liang Liang
- Department of Hepatobiliary and Pancreatic Surgery, Key Laboratory of Combined Multi-Organ Transplantation of Ministry of Public Health, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China
| | - Ting-Bo Liang
- Department of Hepatobiliary and Pancreatic Surgery, Key Laboratory of Combined Multi-Organ Transplantation of Ministry of Public Health, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China,*Ting-Bo Liang:
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31
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Gao PJ, Leng XS, Wang D, Li GM, Huang L, Gao J, Zhu JY. Graft versus host disease after liver transplantation: a case report. ACTA ACUST UNITED AC 2010; 4:469-72. [PMID: 21125347 DOI: 10.1007/s11684-010-0120-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 10/25/2010] [Indexed: 11/26/2022]
Abstract
In documenting clinical experience in the diagnosis and treatment of graft versus host disease (GVHD), we retrospectively analyzed data of one case that has developed GVHD after liver transplantation. This patient exhibited fever, skin rash, and diarrhea on day 9 after liver transplantation. His liver function was normal. Skin biopsy showed scattered keratinocytes accompanied by satellite-like lymphocyte infiltration and basal cell liquefaction degeneration. After carefully analyzing the complications, we took the strategy of decreasing the dose of tacrolimus. Thereafter, the patient's temperature decreased to normal, his skin rashes subsided, and his diarrhea was relieved. This case suggests that reducing the dosage of immunosuppressive agents can be an effective strategy for GVHD after liver transplantation.
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Affiliation(s)
- Peng-Ji Gao
- Center of Hepatobiliary Surgery, Peking University People's Hospital, Beijing, 100044, China
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32
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Xu G, Wang L, Chen W, Xue F, Bai X, Liang L, Shen X, Zhang M, Xia D, Liang T. Rapamycin and tacrolimus differentially modulate acute graft-versus-host disease in rats after liver transplantation. Liver Transpl 2010; 16:357-63. [PMID: 20209637 DOI: 10.1002/lt.22003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute graft-versus-host disease (aGVHD) is a serious complication of liver transplantation (LTx); it occurs in 1% to 2% of liver allograft recipients. The condition has a poor prognosis and poses major diagnostic and therapeutic challenges. A rat model of aGVHD after LTx has been developed, and a relative decrease in regulatory T (Treg) cells has been shown to be associated with this model. Interest has been expressed in the effects of different immunosuppressive agents on CD4+CD25+Foxp3+ Treg cell homeostasis. Rats with aGVHD after LTx were treated with tacrolimus (FK506), rapamycin (RAPA), or no immunosuppressive drug. Those that received RAPA survived longer (91.4 + or - 8.1 days) than those in the FK506 group (62.3 + or - 13.4 days) or the control group (22.9 + or - 1.2 days). Flow cytometry analysis showed that Treg cells, as a percentage of peripheral blood mononuclear cells (PBMCs), were more abundant in the RAPA group (6.8% + or - 0.8%) than in the FK506 group (1.7% + or - 0.4%) or the control group (2.0% + or - 0.4%). Immunohistochemistry demonstrated more Foxp3+ staining of intestinal cells in the RAPA group than in the FK506 group or the control group. In conclusion, the reduced mortality induced by RAPA in a rat model of aGVHD after LTx was associated with higher percentages of CD4+CD25+Foxp3+ Treg cells in PBMCs in blood and tissues than those occurring after the administration of FK506.
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Affiliation(s)
- Guodong Xu
- Department of Hepatobiliary and Pancreatic Surgery, Key Laboratory of Combined Multiorgan Transplantation (Ministry of Public Health), First Affiliated Hospital, Hangzhou, People's Republic of China
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33
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Xue F, Chen W, Wang X, Liang L, Bai X, Wang L, Wang H, Liang T. Establishment of an Acute Graft-Versus-Host Disease Model Following Liver Transplantation in Donor-Dominant One-Way Major Histocompatibility Complex Matching Rats. Transplant Proc 2009; 41:1914-20. [DOI: 10.1016/j.transproceed.2008.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2008] [Accepted: 11/14/2008] [Indexed: 01/16/2023]
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34
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Kanehira K, Riegert-Johnson DL, Chen D, Gibson LE, Grinnell SD, Velgaleti GV. FISH diagnosis of acute graft-versus-host disease following living-related liver transplant. J Mol Diagn 2009; 11:355-8. [PMID: 19460938 DOI: 10.2353/jmoldx.2009.080172] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Acute graft-versus-host disease (GVHD) is an uncommon but often fatal complication following liver transplant. We describe a GVHD case in which a female patient with primary biliary cirrhosis underwent a living-related liver transplant from her son. The human leukocyte antigen typing of the donor was homozygous at all loci. The recipient's human leukocyte antigen type was haplo-identical to that of the donor. A bone marrow aspirate performed for pancytopenia revealed a severely hypoplastic marrow. Fluorescent in situ hybridization (FISH) using X- and Y-chromosome probes demonstrated that 80% of marrow cells were of donor origin. Comparison of Giemsa-stained cell morphology and FISH showed that the erythroid precursor cells were predominantly of male pattern (XY). This report is one of only a few studies that prove the migration of a donor's hematopoietic stem cells to a recipient's bone marrow. We demonstrated that FISH analysis using sex chromosome probes is useful to confirm a diagnosis of GVHD following organ transplantation from a donor of the opposite sex. We also showed that donor hematopoietic stem cells in a liver graft can migrate to the recipient's bone marrow. We suggest that FISH is a rapid and reliable test for confirming the diagnosis of GVHD in a peripheral blood or skin biopsy sample.
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Affiliation(s)
- Kazunori Kanehira
- Departments of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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35
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Thin L, Macquillan G, Adams L, Garas G, Seow C, Cannell P, Augustson B, Mitchell A, Delriveire L, Jeffrey G. Acute graft-versus-host disease after liver transplant: novel use of etanercept and the role of tumor necrosis factor alpha inhibitors. Liver Transpl 2009; 15:421-6. [PMID: 19326415 DOI: 10.1002/lt.21704] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Acute graft-versus-host disease following orthotopic liver transplantation is a rare but feared complication arising in 1% to 2% of cases with a dismal prognosis. It most often presents as fever, rash, and diarrhea with or without pancytopenia. Patients die from complications of marrow failure such as sepsis or bleeding. Because of its low incidence, there is no clear treatment protocol for this complication. Both increasing and withdrawing immunosuppression have been attempted with variable success. Although anti-tumor necrosis factor alpha therapy has been widely used for the treatment of steroid-resistant acute graft-versus-host disease in the hematopoietic stem cell transplant setting, there previously have been no reported cases of its use in liver transplantation. The aim of this report is to review a case of acute graft-versus-host disease and the use of etanercept to manage this complication. Etanercept has never previously been used in liver transplantation complicated by acute graft-versus-host disease. In the hematology literature, the success of its use is offset by significant rates of serious infectious (especially fungal) complications. However, preliminary results are encouraging and offer insight into its use as a potentially viable therapeutic option. We report the first successful use of etanercept in liver transplantation-associated graft-versus-host disease, albeit complicated by invasive aspergillosis, and recommend concurrent antifungal prophylaxis when the drug is used in this setting.
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Affiliation(s)
- Lena Thin
- West Australian Liver Transplant Service, Perth, Western Australia, Australia.
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36
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Xue F, Chen W, Wang X, Wang L, Xu G, Liang L, Bai X, Liang T. Regulatory T cells contribute to the immunoregulatory effect on graft versus host reaction after liver transplantation in donor-dominant one-way MHC matching rats. Transpl Immunol 2009; 20:232-7. [DOI: 10.1016/j.trim.2008.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Revised: 10/24/2008] [Accepted: 11/03/2008] [Indexed: 11/26/2022]
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37
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Kohler S, Pascher A, Junge G, Sauer IM, Nagy M, Schönemann C, Koch M, Neumann U, Pratschke J, Neuhaus P. Graft versus host disease after liver transplantation - a single center experience and review of literature. Transpl Int 2008; 21:441-51. [PMID: 18266778 DOI: 10.1111/j.1432-2277.2007.00625.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Graft versus host disease (GvHD) after liver transplantation has an incidence of 0.1-1%. It is an infrequent but severe and mostly lethal complication. Approximately, 80 cases have been reported in literature so far. A single center experience is reported retrospectively. We performed a retrospective analysis of 1815 liver transplants in our center, transplanted over a period of 17 years. Five patients (5/1815 = 0.28%) with histologically diagnosed GvHD were included in the analysis. Onset of GvHD was between postoperative day (POD) 20 and 60. All patients developed skin rash, being the first symptom in four cases; one patient had joint pain as initial symptom. Macrochimerism was confirmed in all patients. Treatment consisted of augmentation of baseline immunosuppression (n = 4), methylprednisolone (n = 4), and T-cell depleting antibodies (n = 3). One patient received no specific therapy because of her deleterious condition. All patients died because of either haemorrhage or uncontrollable infections. In our experience, GvHD has been an extremely rare, albeit deleterious clinical condition, which was resistant to classical immunosuppressive rescue regimens.
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Affiliation(s)
- Sven Kohler
- Department of Visceral and Transplant Surgery, Charité-Universitaetsmedizin Berlin, Berlin, Germany.
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38
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Perri R, Assi M, Talwalkar J, Heimbach J, Hogan W, Moore SB, Rosen CB. Graft vs. host disease after liver transplantation: a new approach is needed. Liver Transpl 2007; 13:1092-9. [PMID: 17663410 DOI: 10.1002/lt.21203] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Graft-vs.-host disease (GVHD) is a rare, serious complication of orthotopic liver transplantation (OLT). We have treated 5 patients to date with GVHD after OLT. A total of 78 patients worldwide have been reported to have experienced this complication. The means by which GVHD after OLT has been managed is guided by experience with the more common GVHD that occurs after stem cell transplantation. However, despite the use of various treatment modalities, the mortality of GVHD after OLT remains high. This case series and review of the literature demonstrates that successful resolution of GVHD after OLT cannot be expected with the use of those modalities that have been tried to date. It is imperative that new treatments be applied to GVHD after OLT in order to improve the prognosis of patients with this diagnosis.
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Affiliation(s)
- Roman Perri
- Department of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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39
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Chan EY, Larson AM, Gernsheimer TB, Kowdley KV, Carithers RL, Reyes JD, Perkins JD. Recipient and donor factors influence the incidence of graft-vs.-host disease in liver transplant patients. Liver Transpl 2007; 13:516-22. [PMID: 17394149 DOI: 10.1002/lt.21082] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Acute cellular graft-vs.-host disease (GVHD) following liver transplantation has an incidence of 1 to 2% and a mortality rate of 85%. Our aim was to identify a patient population at high risk for developing GVHD using a large clinical database to study both recipient and donor factors. We compared our liver transplant patients who developed GVHD to those that did not for recipient and donor factors and combinations of factors. For 2003-2004 we had 205 first-time liver transplant patients surviving >30 days. From this group, 4 (1.9%) developed GVHD. Compared to the control group, there were no significant differences in recipient age, recipient gender, donor age, donor gender, total ischemia time, donor-recipient human leukocyte antigen (HLA) mismatch, or donor-recipient age difference. Percentages of liver disease etiologies among the patients who developed GVHD were as follows: 16% (1/6) autoimmune hepatitis (AIH) (P = 0.003), 5.6% (3/54) alcoholic liver disease (ALD) (P = 0.057), and 7.1% (3/42) hepatocellular carcinoma (HCC) (P = 0.026). The incidence of GVHD in patients with glucose intolerance (either Type I or Type II diabetes mellitus [DM]) was significant (P = 0.022). Focusing on patients only with high-risk factors for GVHD during the years 2003-2005, we had 19 such patients. Four of these high-risk patients developed GVHD. Three of these 4 patients had received a donor liver with steatosis of degree >or=mild compared to only 2 of the 15 high-risk patients who did not develop GVHD (P = 0.037). In conclusion, we have identified liver transplant patients with AIH or the combination of ALD, HCC, and glucose intolerance who receive a steatotic donor liver as being at high risk for developing GVHD.
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Affiliation(s)
- Edie Y Chan
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, WA 98195, USA
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40
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Assi MA, Pulido JS, Peters SG, McCannel CA, Razonable RR. Graft-vs.-host disease in lung and other solid organ transplant recipients. Clin Transplant 2007; 21:1-6. [PMID: 17302584 DOI: 10.1111/j.1399-0012.2006.00573.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Graft-vs.-host disease (GVHD) is an uncommon complication of solid organ transplantation. Herein, we report a case of GVHD occurring in a lung transplant recipient and review 29 reported cases of GVHD that complicated thoracic organ, and non-hepatic intra-abdominal organ transplantation. The major presenting clinical symptom of GVHD was skin rash. Less frequent clinical manifestations were cytopenia (16%), diarrhea (11%), and fever (5%). The mainstay of treatment was high-dose corticosteroids. The mortality rate was high (30%). The cause of death was mainly due to infection, suggesting that antimicrobial prophylaxis may improve the outcome of this potentially fatal complication.
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Affiliation(s)
- Maha A Assi
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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41
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Sun B, Zhao C, Xia Y, Li G, Cheng F, Li J, Zhang F, Wang X. Late onset of severe graft-versus-host disease following liver transplantation. Transpl Immunol 2006; 16:250-3. [PMID: 17138062 DOI: 10.1016/j.trim.2006.08.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Revised: 07/11/2006] [Accepted: 08/03/2006] [Indexed: 01/31/2023]
Abstract
Graft versus host disease (GVHD) is an uncommon but lethal complication following liver transplantation that results from the engraftment of T lymphocytes associated with the liver graft. It usually occurs 2 to 6 weeks after the procedure. We herein report a case of late onset of severe GVHD 4 months after cadaveric liver transplantation for hepatocellular carcinoma in a 54-year-old woman, which was characterized by refractory diarrhea and abdominal pain. Moreover we discuss risk factors of GVHD including the recipient age and cytomegalovirus (CMV) infection.
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Affiliation(s)
- Beicheng Sun
- National Institute of Living Donor Liver Transplantation, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu 210029, P.R. China.
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42
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Kamei H, Oike F, Fujimoto Y, Yamamoto H, Tanaka K, Kiuchi T. Fatal graft-versus-host disease after living donor liver transplantation: differential impact of donor-dominant one-way HLA matching. Liver Transpl 2006; 12:140-5. [PMID: 16382466 DOI: 10.1002/lt.20573] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Graft-versus-host disease (GVHD) is an uncommon but potentially devastating complication following liver transplantation. Recently, it was shown that use of a human leukocyte antigen (HLA)-homozygous donor leading to one-way HLA matching significantly increases the risk of GVHD after living donor liver transplantation (LDLT). However, the precise impact of HLA matching between donor and recipient on the risk of GVHD is not yet clear. We surveyed instances of fatal GVHD following LDLT in Japan and reviewed all 8 cases in detail, especially with respect to HLA matching. Serological typing showed that 7 of those cases had donor-dominant one-way HLA matching in the 3 loci of HLA-A, -B, and -DR, while one had donor-dominant one-way HLA matching in the 2 loci of HLA-A and -DR and identical alleles in the B locus. However, DNA typing revealed that the latter case had 1-way HLA matching in the 3 loci. Further, we analyzed HLA typing of 906 donor-recipient pairs who underwent LDLT. There were 5 cases with donor-dominant one-way matching in 2 loci and 2 with donor-dominant one-way matching in 1 locus. All of those cases except 1, who died from an unrelated cause, are alive without an obvious presentation of GVHD. In conclusion, our results suggest that the total number of loci with donor-dominant one-way HLA matching is important for determining the risk of fatal GVHD following LDLT, and that DNA typing of HLA alleles is indispensable in some cases to identify the true risk of donor-dominant 1-way HLA matching.
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Affiliation(s)
- Hideya Kamei
- Department of Transplantation Surgery, Nagoya University Hospital, Nagoya, Japan.
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Abstract
The increasing awareness of liver diseases and their early detection have led to an increase in the number of transplant waiting list candidates over the past decade. This need has not been matched by the actual number of orthotopic liver transplantations performed. Live donor liver transplantation (LDLT) is an innovative surgical technique intended to expand the available organ donor pool. Although LDLT offers definite advantages to the recipient, it offers none to the donor except for the possibility of psychological well-being. Clinical research studies aimed at the prospective collection of data for donors and recipients need to be conducted.
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Affiliation(s)
- Lawrence U Liu
- Division of Liver Diseases, The Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1104, New York, NY 10039, USA
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Whalen JG, Jukic DM, English JC. Rash and pancytopenia as initial manifestations of acute graft-versus-host disease after liver transplantation. J Am Acad Dermatol 2005; 52:908-12. [PMID: 15858489 DOI: 10.1016/j.jaad.2005.01.126] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Acute graft-versus-host disease is mainly a complication of allogeneic bone-marrow transplantation, and rarely seen after transplantation of solid organs. We describe a 68-year-old man who developed a maculopapular eruption and fever approximately 15 days after orthotopic liver transplantation for cryptogenic cirrhosis. At day 19, the patient developed abrupt neutropenia and diarrhea. Skin biopsy was performed and the specimen revealed basal cell layer vacuolization, necrotic keratinocytes, and satellite cell necrosis. Bone-marrow aspiration performed after the patient became pancytopenic revealed aplastic marrow with scattered lymphocytes and rare megakaryocytes. A diagnosis of acute graft-versus-host disease was made and an immunosuppressive drug regimen was initiated. Unfortunately, the patient died after support was withdrawn because of total ablation of his bone marrow and multiorgan failure. This report describes the rare presentation of acute graft-versus-host disease after solid organ transplantation, and that skin manifestations may be an early presenting sign.
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Affiliation(s)
- Jason G Whalen
- Department of Dermatology, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
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Barshes NR, Myers GD, Lee D, Karpen SJ, Lee TC, Patel AJ, Finegold M, Goss JA. Liver transplantation for severe hepatic graft-versus-host disease: an analysis of aggregate survival data. Liver Transpl 2005; 11:525-31. [PMID: 15838886 DOI: 10.1002/lt.20389] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Graft-versus-host disease (GVHD) often occurs after bone marrow transplantation (BMT). GVHD may lead to cirrhosis or complete destruction of the bile ducts, and few effective treatment options exist for such cases. Orthotopic liver transplantation (OLT) has been described as an option, but to date the patient survival, graft survival, and GVHD recurrence rates after OLT have been unknown. Cases of OLT for GVHD were accumulated from several sources: (1) cases of OLT performed at a single institution, (2) the English-language medical literature, and (3) the United Network for Organ Sharing (UNOS) liver transplant registry. Descriptive data were derived from pre- and post-OLT information; survival analysis was performed using the Kaplan-Meier method. One case of OLT for GVHD after BMT was found at our institution, and another 6 cases were previously reported in the literature. Extrahepatic GVHD recurred in 2 cases, but no recurrence of hepatic GVHD was reported. The UNOS registry contained an additional 73 patients who underwent OLT for hepatic GVHD. The 1- and 5-year actuarial patient survival rates were 72.4% and 62.9%, respectively. Although 4 patients required retransplantation, no deaths or retransplants were attributed to the recurrence of hepatic GVHD. OLT is an effective treatment for hepatic GVHD after BMT or non-liver organ transplant. Long-term disease-free survival is obtainable in these cases, and recurrence of hepatic GVHD has not been reported. These findings suggest that OLT should be considered as an effective treatment option for cases of hepatic GVHD recalcitrant to medical treatment.
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Affiliation(s)
- Neal R Barshes
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
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