Graft-vs-Host Disease as a Complication of Lung Transplantation

How I diagnose and treat acute graft-versus-host disease after solid organ transplantation

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.

Graft-vs-Host Disease Colitis After Lung Transplant

Graft-vs-host disease, characteristically a major complication of allogenic hematopoietic stem cell transplantation, is rare after solid organ transplantation. We report a 50-year-old man who presented with abdominal pain, vomiting, and diarrhea shortly after bilateral lung transplantation. Colonoscopy with biopsy revealed diffuse severe active colitis with ulceration and crypt apoptosis consistent with graft-vs-host disease colitis. The diagnosis was confirmed by the presence of donor lymphocytes in the peripheral blood. His symptoms were refractory to corticosteroids but responded to the addition of infliximab and extracorporeal photophoresis. He remained in remission 17 months later.

Dermatologic manifestations of solid organ transplantation-associated graft-versus-host disease: A systematic review

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.

Severe acute graft versus host disease after lung transplant: report of a case successfully treated with high dose corticosteroids

Acute graft vs host disease is an uncommon and usually fatal complication of lung transplant for which no effective therapy exists. All 8 patients with grade 3 to 4 acute graft vs host disease after lung transplantation described in literature died within 208 days. We report a patient with grade 3 to 4 acute graft vs host disease after bilateral lung transplantation who was successfully treated with high-dose corticosteroids after basiliximab and extracorporeal photopheresis were unsuccessful.

Priming donor lungs with thioredoxin-1 attenuates acute allograft injury in a rat model of lung transplantation

BACKGROUND

Lung graft dysfunction and rejection are significant causes of morbidity and mortality in transplant recipients. Thioredoxin-1, a redox-regulatory protein, functions as an antioxidant in multiple organs, including lungs. We examined whether priming of the donor lungs with thioredoxin-1 before transplantation attenuates acute lung injury.

METHODS

Orthotopic left lung transplantation was performed from Lewis (donor) to Sprague-Dawley (recipient) rats. Donor lungs were perfused and stored in Perfadex solution (Vitrolife, Uppsala, Sweden), with or without purified thioredoxin-1. Changes in bronchoalveolar lavage (BAL) analysis, allograft oxygen exchange function, nuclear factor kappaB (NF-kappaB)/DNA binding, myeloperoxidase activities, and immunohistologic evaluation of neutrophils, macrophages, and cytotoxic T-cells (CD8(+)) infiltration were examined in post-transplant allograft (left) and native (right) lungs at Days 1 and 5.

RESULTS

BAL cell differential analysis showed significant increases in macrophages and neutrophils in allografts at Day 1 post-transplant. At Days 1 and 5, lymphocyte infiltration was significantly increased and myeloperoxidase and NF-kappaB/DNA binding activities were increased vs basal activities. Immunohistology staining revealed increased infiltration of macrophages, neutrophils, and CD8(+) T cell sub-sets. Pre-transplant priming of donor lungs with thioredoxin-1 improved oxygen exchange and attenuated NF-kappaB/DNA binding activity, and infiltration of macrophages, neutrophils, and CD8(+) T cell sub-sets in allografts at Days 1 and 5 post-transplant.

CONCLUSIONS

Priming of donor lungs with thioredoxin-1 before transplant attenuates acute allograft injury in a rat model of lung transplantation, and appears to be associated with the antioxidant function of thioredoxin-1 that limits early ischemia-reperfusion injury, NF-kappaB activation, and progressive infiltration of inflammatory and immune cells in allografts.

Allorecognition and the alloresponse: clinical implications

The artificial transfer of tissues or cells between genetically diverse individuals elicits an immune response that is adaptive and specific. This response is orchestrated by T lymphocytes that are recognizing, amongst others, major histocompatibility complex (MHC) molecules expressed on the surface of the transferred cells. Three pathways of recognition are described: direct, indirect and semi-direct. The sets of antigens that are recognized in this setting are also discussed, namely, MHC protein products, the MHC class I-related chain (MIC) system, minor histocompatibility antigens and natural killer cell receptor ligands. The end product of the effector responses are hyperacute, acute and chronic rejection. Special circumstances surround the situation of pregnancy and bone marrow transplantation because in the latter, the transferred cells are the ones originating the immune response, not the host. As the understanding of these processes improves, the ability to generate clinically viable immunotherapies will increase.