1
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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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2
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Chen Z, Han C, Wang X, He Y, Liang T, Mo S, Li X, Zhu G, Su H, Ye X, Lv Z, Shang L, Wen Z, Peng M, Peng T. Graft versus host disease after liver transplantation following radiotherapy for the treatment of hepatocellular carcinoma: A case report and literature review. SAGE Open Med Case Rep 2022; 10:2050313X221101747. [PMID: 35646373 PMCID: PMC9136437 DOI: 10.1177/2050313x221101747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 04/27/2022] [Indexed: 11/16/2022] Open
Abstract
Graft versus host disease after solid organ transplantation is very rare. This article reports a case of graft versus host disease after liver transplantation following targeted therapy and radiotherapy for the treatment of hepatocellular carcinoma. The patient developed a symptomatic skin rash and pancytopenia 13 days after surgery, which was confirmed as graft versus host disease after liver transplantation by histopathology and fluorescence in situ hybridization. Early diagnosis of graft versus host disease after solid organ transplantation is difficult and often delayed due to nonspecific manifestations that overlap with other diseases. Currently, the treatment of graft versus host disease after liver transplantation occurs by either strengthening the immune suppression or weakening the immune suppression; however, there is no unified standard treatment strategy. We found that in addition to age, gender, and human leukocyte antigen type, preoperative radiotherapy is a likely risk factor for graft versus host disease after liver transplantation.
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Affiliation(s)
- Zijun Chen
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Chuangye Han
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiangkun Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yongfei He
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Tianyi Liang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shutian Mo
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xuan Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Guangzhi Zhu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Hao Su
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xinping Ye
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zili Lv
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Liming Shang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zhang Wen
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Minhao Peng
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Tao Peng
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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3
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Xiao JJ, Ma JY, Liao J, Wu D, Lv C, Li HY, Zuo S, Zhu HT, Gu HJ. Fluorescence in situ hybridization-based confirmation of acute graft- vs-host disease diagnosis following liver transplantation: A case report. World J Gastrointest Surg 2021; 13:1102-1109. [PMID: 34621484 PMCID: PMC8462082 DOI: 10.4240/wjgs.v13.i9.1102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 06/13/2021] [Accepted: 07/20/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Although acute graft-vs-host disease (aGvHD) is a rare complication of liver transplantation, it is poorly understood and has an extremely high mortality rate. No standardized diagnostic criteria or treatment regimens currently exist.
CASE SUMMARY The present study investigated the etiology, diagnosis, and treatment of aGvHD following liver transplantation. Presentation, diagnosis, disease course, histology, and treatment of an aGvHD case are reported, and associated literature is reviewed. A 64-year-old female required LTx due to primary biliary cirrhosis. The donor was a 12-year-old male. Three weeks following liver transplantation, the recipient developed pyrexia, diarrhea, rashes, and antibiotic-unresponsive pancytopenia. Clinical symptoms together with laboratory investigations suggested a diagnosis of aGvHD, which was confirmed via peripheral blood fluorescent in situ hybridization. Donor XY chromosome fluorescent in situ hybridization indicating early chimerism achieved 93% sensitivity in the detection of GvHD. Existing immunosuppressants were discontinued, and high-dose intravenous methylprednisolone was initiated along with antibiotics. While diarrhea resolved, the patient’s general condition continued to deteriorate until demise due to multi-system organ failure at 37 d post-liver transplantation. This case illustrates the life-threatening nature of aGvHD.
CONCLUSION Herein, we have summarized a post-LTx aGvHD case and reviewed associated literature in order to increase awareness and provide potentially risk-mitigating recommendations.
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Affiliation(s)
- Jing-Jing Xiao
- School of Clinical Medicine, Guizhou Medical University, Guiyang 550004, Guizhou Province, China
| | - Jin-Yu Ma
- School of Clinical Medicine, Guizhou Medical University, Guiyang 550004, Guizhou Province, China
| | - Jun Liao
- School of Clinical Medicine, Guizhou Medical University, Guiyang 550004, Guizhou Province, China
| | - Di Wu
- School of Clinical Medicine, Guizhou Medical University, Guiyang 550004, Guizhou Province, China
| | - Chao Lv
- School of Clinical Medicine, Guizhou Medical University, Guiyang 550004, Guizhou Province, China
| | - Hai-Yang Li
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou Province, China
| | - Shi Zuo
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou Province, China
| | - Hai-Tao Zhu
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou Province, China
| | - Hua-Jian Gu
- Department of Pediatric Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou Province, China
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4
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Zuber J, Boyer O, Neven B, Jollet I, Renac V, Berthaud R, Levy R, Lamarthée B, Visentin J, Marchal A, Gouge-Biebuyck N, Godron-Dubrasquet A, Aladjidi N, Rabah MO, Winter S, Léon J, Dussiot M, Rabant M, Krid S, Krug P, Charbit M, Lacaille F, André I, Cavazzana M, Llanas B, Allard L, Pirenne F, Gross S, Djoudi R, Tiberghien P, Taupin JL, Blanche S, Salomon R. Donor-targeted serotherapy as a rescue therapy for steroid-resistant acute GVHD after HLA-mismatched kidney transplantation. Am J Transplant 2020; 20:2243-2253. [PMID: 32065452 DOI: 10.1111/ajt.15827] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/31/2020] [Accepted: 02/04/2020] [Indexed: 02/06/2023]
Abstract
Acute graft-versus-host disease (GVHD) is a rare but frequently lethal complication after solid organ transplantation. GVHD occurs in unduly immunocompromised hosts but requires the escalation of immunosuppression, which does not discriminate between host and donor cells. In contrast, donor-targeted therapy would ideally mitigate graft-versus-host reactivity while sparing recipient immune functions. We report two children with end-stage renal disease and severe primary immune deficiency (Schimke syndrome) who developed severe steroid-resistant acute GVHD along with full and sustained donor T cell chimerism after isolated kidney transplantation. Facing a therapeutic dead end, we used a novel strategy based on the adoptive transfer of anti-HLA donor-specific antibodies (DSAs) through the transfusion of highly selected plasma. After approval by the appropriate regulatory authority, an urgent nationwide search was launched among more than 3800 registered blood donors with known anti-HLA sensitization. Adoptively transferred DSAs bound to and selectively depleted circulating donor T cells. The administration of DSA-rich plasma was well tolerated and notably did not induce antibody-mediated rejection of the renal allografts. Acute GVHD symptoms promptly resolved in one child. This report provides a proof of concept for a highly targeted novel therapeutic approach for solid organ transplantation-associated GVHD.
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Affiliation(s)
- Julien Zuber
- Paris University, Paris, France.,Laboratory of Human Lymphohematopoiesis, Inserm UMR 1163, Imagine Institute, Paris, France.,Department of Adult Kidney Transplantation, Necker Hospital, Paris, France
| | - Olivia Boyer
- Paris University, Paris, France.,Department of Pediatric Nephrology and Kidney Transplantation, Necker Hospital, Paris, France
| | - Bénédicte Neven
- Paris University, Paris, France.,Department of Pediatric Immuno-hematology, Necker Hospital, Paris, France
| | - Isabelle Jollet
- Etablissement Français du Sang Nouvelle Aquitaine, HLA Laboratory, Poitiers, France
| | - Virginie Renac
- Etablissement Français du Sang Bretagne, HLA Laboratory, Rennes, France
| | - Romain Berthaud
- Paris University, Paris, France.,Department of Pediatric Nephrology and Kidney Transplantation, Necker Hospital, Paris, France
| | - Romain Levy
- Paris University, Paris, France.,Department of Pediatric Immuno-hematology, Necker Hospital, Paris, France
| | - Baptiste Lamarthée
- Laboratory of Human Lymphohematopoiesis, Inserm UMR 1163, Imagine Institute, Paris, France
| | - Jonathan Visentin
- CHU de Bordeaux, Laboratoire d'Immunologie et Immunogénétique, Hôpital Pellegrin, Bordeaux, France.,Immuno ConcEpT, UMR CNRS 5164, Bordeaux, France.,Université de Bordeaux, Bordeaux, France
| | - Armance Marchal
- Laboratory of Human Lymphohematopoiesis, Inserm UMR 1163, Imagine Institute, Paris, France
| | - Nathalie Gouge-Biebuyck
- Department of Pediatric Nephrology and Kidney Transplantation, Necker Hospital, Paris, France
| | - Astrid Godron-Dubrasquet
- Department of Pediatric Nephrology and Kidney Transplantation, Pellegrin Hospital, Bordeaux, France
| | - Nathalie Aladjidi
- Department of Pediatric Onco-Hematology, Pellegrin Hospital, Bordeaux, France
| | - Melissa O Rabah
- Paris University, Paris, France.,Department of Pediatric Nephrology and Kidney Transplantation, Necker Hospital, Paris, France
| | - Sarah Winter
- Paris University, Paris, France.,Department of Pediatric Immuno-hematology, Necker Hospital, Paris, France
| | - Juliette Léon
- Department of Pathology, Necker Hospital, Paris, France
| | - Michael Dussiot
- Laboratory of Molecular Mechanisms of Hematologic Disorders and Therapeutic Implications, Inserm UMRS 1163, Imagine Institute, Paris, France
| | - Marion Rabant
- Paris University, Paris, France.,Department of Pathology, Necker Hospital, Paris, France
| | - Saoussen Krid
- Department of Pediatric Nephrology and Kidney Transplantation, Necker Hospital, Paris, France
| | - Pauline Krug
- Department of Pediatric Nephrology and Kidney Transplantation, Necker Hospital, Paris, France
| | - Marina Charbit
- Department of Pediatric Nephrology and Kidney Transplantation, Necker Hospital, Paris, France
| | - Florence Lacaille
- Department of Pediatric Gastroenterology-Hepatology-Nutrition Unit, Necker Hospital, Paris, France
| | - Isabelle André
- Laboratory of Human Lymphohematopoiesis, Inserm UMR 1163, Imagine Institute, Paris, France
| | - Marina Cavazzana
- Paris University, Paris, France.,Laboratory of Human Lymphohematopoiesis, Inserm UMR 1163, Imagine Institute, Paris, France.,Biotherapy Clinical Investigation Center, Necker Hospital, Paris, France
| | - Brigitte Llanas
- Department of Pediatric Nephrology and Kidney Transplantation, Pellegrin Hospital, Bordeaux, France
| | - Lise Allard
- Department of Pediatric Nephrology and Kidney Transplantation, Pellegrin Hospital, Bordeaux, France
| | - France Pirenne
- Etablissement Français du Sang, Ile-de-France, Créteil, France.,Etablissement Français du Sang, St. Denis, France
| | - Sylvie Gross
- Etablissement Français du Sang, St. Denis, France
| | | | - Pierre Tiberghien
- Etablissement Français du Sang, St. Denis, France.,Etablissement Français du Sang, UMR 1098, Inserm, Université de Franche-Comté, Besançon, France
| | - Jean-Luc Taupin
- Laboratory of Immunology and Histocompatibility, Saint Louis Hospital, Paris, France
| | - Stéphane Blanche
- Paris University, Paris, France.,Department of Pediatric Immuno-hematology, Necker Hospital, Paris, France
| | - Rémi Salomon
- Paris University, Paris, France.,Department of Pediatric Nephrology and Kidney Transplantation, Necker Hospital, Paris, France
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5
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Hematopoietic Stem Cell Transplantation in Solid Organ Recipients with Emphasis on Transplant Complications: A Nationwide Retrospective Survey on Behalf of the Japan Society for Hematopoietic Stem Cell Transplantation Transplant Complications Working Group. Biol Blood Marrow Transplant 2019; 26:66-75. [PMID: 31494230 DOI: 10.1016/j.bbmt.2019.08.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 07/28/2019] [Accepted: 08/23/2019] [Indexed: 12/18/2022]
Abstract
Little is known about stem cell transplantation in solid organ transplantation (SOT) recipients. We conducted a nationwide retrospective survey of Japan Society for Hematopoietic Stem Cell Transplantation centers. A total of 19 patients who underwent 22 hematopoietic stem cell transplantations (HSCTs) after SOT were identified: 5 autologous HSCTs and 17 allogeneic HSCTs were performed. Patients who underwent autologous HSCT received a liver (n = 4) or kidney (n = 1) transplant. All 5 patients achieved neutrophil engraftment, and 2 of 3 patients with hepatoblastoma were alive at 1 year after HSCT. Allogeneic HSCT was performed in 16 patients (7 liver transplant recipients and 9 kidney transplant recipients). Among these, 2 donors were identical for both transplantations. All but 1 patient achieved neutrophil engraftment. The 5-year overall survival rate was 41.7%, but that in patients with malignant disease (n = 13) was much lower than the overall rate (23.1%). Only 1 patient with malignant disease underwent allogeneic HSCT in nonremission. In allogeneic HSCT after kidney transplantation, post-transplantation (1 year) kidney function in 5 evaluable patients was significantly lower than that before allogeneic HSCT, and 3 patients experienced renal rejection. However, no severe hepatic rejection was noted. In SOT recipients, HSCT is a potentially curable treatment for hematologic disorders, but it must be performed with caution, especially in patients with malignancy.
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6
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Hoogenboom L, Margolis D, Anderson L, Phelan R. Sequential transplantation and implications for clinical management: OLT followed by HCT and consequent RT in a pediatric patient. Pediatr Transplant 2019; 23:e13370. [PMID: 30779289 DOI: 10.1111/petr.13370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 11/29/2018] [Accepted: 12/21/2018] [Indexed: 02/02/2023]
Abstract
We report a case of a pediatric patient who required three separate transplants: OLT at the age 5, HCT at age 13 (8 years post-OLT), and cadaveric RT at age 15 (10 years post-OLT). The child initially presented with fulminant liver failure without known cause, ultimately undergoing OLT from his mother. He then developed SAA, for which he required HCT. Unfortunately, he developed ESRD secondary to prolonged CNI exposure, for which he underwent cadaveric RT. These processes then resulted in 7 years largely free from complications, during which a multi-disciplinary team monitored the patient for complications. Regrettably, at the age of 21 he developed poorly differentiated mucinous adenocarcinoma of the colon which ultimately led to his demise. While there are case reports of patients requiring two sequential transplants, there is a paucity of reports of successfully completing three separate organ transplants in the same patient. Our case demonstrates progression of a pediatric patient through OLT, HCT, and RT with discussion of notable clinical implications. Secondarily, this case highlights the importance of coordination of care amongst various subspecialties to facilitate tandem transplantations and manage the complications of these processes. As pediatric patients have improved survival rates and may require multiple transplants, it remains important to highlight the feasibility as well as the complications of the tandem transplant process.
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Affiliation(s)
- Lindsay Hoogenboom
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David Margolis
- Section of Hematology, Oncology and BMT, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lynnette Anderson
- Section of Hematology, Oncology and BMT, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rachel Phelan
- Section of Hematology, Oncology and BMT, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
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7
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Sasaki K, Mori Y, Yoshimoto G, Sakoda T, Kato K, Inadomi K, Kamezaki K, Takenaka K, Iwasaki H, Maeda T, Miyamoto T, Akashi K. Successful treatment of Ph ALL with hematopoietic stem cell transplantation from the same HLA-haploidentical related donor of previous liver transplantation. Leuk Lymphoma 2017; 59:2005-2007. [PMID: 29164981 DOI: 10.1080/10428194.2017.1403021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Kensuke Sasaki
- a Department of Medicine and Biosystemic Science , Kyushu University Graduate School of Medical Sciences , Fukuoka , Japan
| | - Yasuo Mori
- a Department of Medicine and Biosystemic Science , Kyushu University Graduate School of Medical Sciences , Fukuoka , Japan
| | - Goichi Yoshimoto
- a Department of Medicine and Biosystemic Science , Kyushu University Graduate School of Medical Sciences , Fukuoka , Japan
| | - Teppei Sakoda
- a Department of Medicine and Biosystemic Science , Kyushu University Graduate School of Medical Sciences , Fukuoka , Japan
| | - Koji Kato
- a Department of Medicine and Biosystemic Science , Kyushu University Graduate School of Medical Sciences , Fukuoka , Japan
| | - Kyoko Inadomi
- a Department of Medicine and Biosystemic Science , Kyushu University Graduate School of Medical Sciences , Fukuoka , Japan
| | - Kenjiro Kamezaki
- b Center for Cellular and Molecular Medicine , Kyushu University Hospital , Fukuoka , Japan
| | - Katsuto Takenaka
- a Department of Medicine and Biosystemic Science , Kyushu University Graduate School of Medical Sciences , Fukuoka , Japan
| | - Hiromi Iwasaki
- b Center for Cellular and Molecular Medicine , Kyushu University Hospital , Fukuoka , Japan
| | - Takahiro Maeda
- b Center for Cellular and Molecular Medicine , Kyushu University Hospital , Fukuoka , Japan
| | - Toshihiro Miyamoto
- a Department of Medicine and Biosystemic Science , Kyushu University Graduate School of Medical Sciences , Fukuoka , Japan
| | - Koichi Akashi
- a Department of Medicine and Biosystemic Science , Kyushu University Graduate School of Medical Sciences , Fukuoka , Japan.,b Center for Cellular and Molecular Medicine , Kyushu University Hospital , Fukuoka , Japan
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8
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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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9
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Doney KC, Mielcarek M, Stewart FM, Appelbaum FR. Hematopoietic Cell Transplantation after Solid Organ Transplantation. Biol Blood Marrow Transplant 2015; 21:2123-2128. [DOI: 10.1016/j.bbmt.2015.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 08/03/2015] [Indexed: 10/23/2022]
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10
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Basak GW, Wiktor-Jedrzejczak W, Labopin M, Schoemans H, Ljungman P, Kobbe G, Beguin Y, Lang P, Koenecke C, Sykora KW, Te Boome L, van Biezen A, van der Werf S, Mohty M, de Witte T, Marsh J, Dreger P, Kröger N, Duarte R, Ruutu T. Allogeneic hematopoietic stem cell transplantation in solid organ transplant recipients: a retrospective, multicenter study of the EBMT. Am J Transplant 2015; 15:705-14. [PMID: 25648262 DOI: 10.1111/ajt.13017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 08/21/2014] [Accepted: 09/11/2014] [Indexed: 01/25/2023]
Abstract
We conducted a questionnaire survey of the 565 European Society for Blood and Marrow Transplantation centers to analyze the outcome of allogeneic hematopoietic stem cell transplantation (alloSCT) in recipients of solid organ transplantation (SOT). We investigated 28 patients with malignant (N = 22) or nonmalignant diseases (N = 6), who underwent 31 alloSCT procedures: 12 after kidney, 13 after liver and 3 after heart transplantation. The incidence of solid organ graft failure at 60 months after first alloSCT was 33% (95% confidence interval [CI], 16-51%) for all patients, 15% (95% CI, 2-40%) for liver recipients and 50% (95% CI, 19-75%) for kidney recipients (p = 0.06). The relapse rate after alloSCT (22%) was low following transplantation for malignant disorders, despite advanced stages of malignancy. Overall survival at 60 months after first alloSCT was 40% (95% CI, 19-60%) for all patients, 51% (95% CI, 16-86%) for liver recipients and 42% (95% CI, 14-70%) for kidney recipients (p = 0.39). In summary, we show that selected SOT recipients suffering from hematologic disorders may benefit from alloSCT and experience enhanced long-term survival without loss of organ function.
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Affiliation(s)
- G W Basak
- The Medical University of Warsaw, Warsaw, Poland
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11
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Bathla L, Grant WJ, Mercer DF, Vargas LM, Gebhart CL, Langnas AN. Parvovirus associated fulminant hepatic failure and aplastic anemia treated successfully with liver and bone marrow transplantation. A report of two cases. Am J Transplant 2014; 14:2645-50. [PMID: 25179206 DOI: 10.1111/ajt.12857] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 05/30/2014] [Accepted: 05/31/2014] [Indexed: 01/25/2023]
Abstract
Aplastic anemia (AA) has been observed in nearly a third of patients undergoing liver transplantation (LT) for non-A-E fulminant hepatic failure (FHF). Few of these patients have been successfully managed with sequential LT and bone marrow transplantation (BMT). No causative agent has been identified for the FHF or AA in these reported cases. At our center, two patients, aged 15 years and 7 years, respectively, underwent sequential living-related LT and living-unrelated BMT. These patients are 10/9 years and 5/4 years post-LT/BMT. Human parvovirus B19 (HPV-B19) was established as the causative agent for FHF in both these patients by polymerase chain reaction. This report presents the first two cases associating HPV-B19 with FHF and AA who underwent sequential LT and BMT with excellent outcomes.
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Affiliation(s)
- L Bathla
- Methodist Specialty and Transplant Hospital, San Antonio, TX
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12
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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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13
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Tolerance to liver allograft after allogeneic hematopoietic cell transplantation for severe aplastic anemia from the same HLA-matched sibling donor. Bone Marrow Transplant 2011; 47:1128-30. [DOI: 10.1038/bmt.2011.222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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14
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Schechter T, Gassas A, Weitzman S, Grant D, Pollock-BarZiv S, Dipchand A, Alexander S, Ali M, Avitzur Y, Doyle J. Hematopoietic stem-cell transplantation following solid-organ transplantation in children. Bone Marrow Transplant 2011; 46:1321-5. [PMID: 21822316 DOI: 10.1038/bmt.2011.153] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Reports of hematopoietic stem-cell transplantation (HSCT) following solid-organ transplantation have been described in adults mainly as case reports. These reports demonstrate feasibility but likely do not reflect true outcomes due to a positive reporting bias. We report herein the outcomes of all our pediatric recipients of allogeneic HSCT following previous solid-organ transplantation between 2000 and 2009. Four children were identified. Two patients underwent heart transplantation followed by cord-blood allogeneic HSCT for T-cell lymphoma/post transplant lymphoproliferative disease (PTLD) and two patients underwent liver transplantation followed by living-donor allogeneic HSCT for severe aplastic anemia (SAA). The mean time between transplants was 4.2 years (range 1.5-6 years). All patients engrafted; however, all patients died from 37 days to 1 year after HSCT. Causes of death included infections (n=2), multi-organ failure (n=1) and solid-organ graft rejection (n=1). Though three patients survived beyond day+100, multiple complications were observed including EBV re-activation followed by EBV-positive PTLD (n=1) and five episodes of severe infections. The patients transplanted for lymphoma did not have evidence of recurrence at last follow-up. Although feasibilty has been shown with this cohort, we conclude that allogeneic HSCT in immunosuppressed patients following solid-organ transplantation remains a very high risk procedure that results in severe morbidity and mortality in children.
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Affiliation(s)
- T Schechter
- Department of Paediatrics, Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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15
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Smiers FJ, Van de Vijver E, Delsing BJP, Lankester AC, Ball LM, Rings EHHM, van Rheenen PF, Bredius RGM. Delayed immune recovery following sequential orthotopic liver transplantation and haploidentical stem cell transplantation in erythropoietic protoporphyria. Pediatr Transplant 2010; 14:471-5. [PMID: 19735434 DOI: 10.1111/j.1399-3046.2009.01233.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
A nine-yr-old boy with EPP suffered from severe skin burns and liver failure caused by progressive cholestasis and fibrosis. OLT was performed without major complications. Four months following liver transplantation he underwent parental haploidentical HSCT. The myeloablative conditioning regimen was relatively well tolerated and hematological engraftment was rapid (on day 10). Protoporphyrin concentrations returned to normal following HSCT. However, immune recovery was significantly delayed. Varicella zoster virus reactivation resulted in impaired vision, prolonged hospitalization and eventually in multiorgan failure and death. Sequential liver and haploidentical HSCT proved feasible though a high risk procedure in this EPP patient. The management of post-IST after these combined transplantations remains a challenge and needs to be further established.
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Affiliation(s)
- Frans J Smiers
- Division of Immunology, Hematology, Oncology, Bone marrow transplantation and Auto-immune disease, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
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16
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Perz JB, Hegenbart U, Kroeger N, Otto G, Ho AD, Dreger P. Successful unrelated donor stem cell transplantation for advanced myelofibrosis in an adult patient with history of orthotopic liver transplantation. Haematologica 2009; 94:594-6. [PMID: 19229047 DOI: 10.3324/haematol.2008.002923] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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17
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Sanchez R, Rosenthal P, Goldsby R. Immunotherapy for severe aplastic anemia following orthotopic liver transplantation in children. Pediatr Blood Cancer 2007; 49:93-8. [PMID: 16395686 DOI: 10.1002/pbc.20718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Severe aplastic anemia is a well-recognized complication of fulminant non-A, non-B, and non-C hepatitis requiring orthotopic liver transplantation. The first line of therapy for cure in the treatment of aplastic anemia is a histocompatible bone marrow transplant. Immunosuppressive therapy is also effective if a histocompatible donor is not available. We describe two children who developed severe aplastic anemia following orthotopic liver transplant who achieved bone marrow recovery with a single course of anti-thymocyte globulin, solumedrol, and adjustments to their immunosuppressive therapy for prevention of liver allograft rejection.
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Affiliation(s)
- Rosa Sanchez
- Department of Pediatrics, University of California, San Francisco, California 94143-0106, USA.
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18
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So K, Macquillan G, Garas G, Delriviere L, Mitchell A, Speers D, Mews C, Augustson B, de Boer WB, Baker D, Jeffrey GP. Urgent liver transplantation for acute liver failure due to parvovirus B19 infection complicated by primary Epstein?Barr virus and cytomegalovirus infections and aplastic anaemia. Intern Med J 2007; 37:192-5. [PMID: 17316340 DOI: 10.1111/j.1445-5994.2006.01293.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
An 11-year-old boy presented with hepatic failure secondary to parvovirus B19 infection, requiring urgent liver transplantation. His recovery was complicated by primary Epstein-Barr virus and cytomegalovirus infections. He subsequently developed aplastic anaemia that has been refractory to antithymocyte globulin and cyclosporine therapy and may now require bone marrow transplantation. We present this case to emphasize parvovirus as a rare cause of hepatic failure and of aplastic anaemia as a complication of the virus.
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Affiliation(s)
- K So
- Western Australian Liver Transplantation Service, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.
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19
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20
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Chakraborty A, Lazova R, Davies S, Bäckvall H, Ponten F, Brash D, Pawelek J. Donor DNA in a renal cell carcinoma metastasis from a bone marrow transplant recipient. Bone Marrow Transplant 2005; 34:183-6. [PMID: 15195072 DOI: 10.1038/sj.bmt.1704547] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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21
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Tessari G, Fabbian F, Colato C, Benedetti F, Franchini M, Ortalda V, Cavallini L, Barba A. Primary cutaneous plasmacytoma after rejection of a transplanted kidney: case report and review of the literature. Int J Hematol 2005; 80:361-4. [PMID: 15615262 DOI: 10.1532/ijh97.e0406] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Immunosuppressed organ allograft recipients are at risk of developing lymphomas and lymphoproliferative disorders as a consequence of immunosuppressive therapy and long-term antigenic stimulation from both the graft and possible viral infections. No more than 4% of the malignant tumors detected in organ recipients are plasmacytomas. Primary cutaneous plasmacytoma is a rare type of cutaneous B-cell lymphoma arising primarily in the skin. It is derived from clonally expanded plasma cells with various degrees of maturation and atypia. We report the occurrence of a solitary cutaneous plasmacytoma in a 56-year-old male patient undergoing hemodialysis after rejection of a grafted kidney. The diagnosis was made a few months after the kidney had been surgically removed. A thorough examination showed no evidence of systemic disease. Skin lesions were successfully treated with local radiotherapy. After 2 years of follow-up there were no local or systemic recurrences.
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22
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Abstract
Anemia is common after liver transplantation, with the incidence ranging from 4.3% to 28.2% depending on the criteria used to define anemia. The cause of anemia is unidentified in the majority of patients, and it is likely to be multifactorial. Immunosuppressive-medication-induced bone marrow suppression is perhaps the most common cause of unexplained anemia. Chronic blood loss, iron deficiency, hemolysis, and renal insufficiency are other potential causes of chronic anemia. Rare causes, somewhat unique to transplantation, include aplastic anemia, graft-versus-host disease (GVHD), and lymphoproliferative disease. Anemia due to immunosuppressive medication is challenging, since almost all drugs currently used for this purpose cause anemia, but the renal-sparing property of sirolimus may benefit the subgroup in which renal insufficiency is contributing to anemia. Aplastic anemia is seen in young patients transplanted for non-A, non-B, non-C, fulminant hepatic failure. It is thought to be immunologically mediated, secondary to an unknown viral infection, and is associated with a grave prognosis. GVHD is another infrequent (approximately 1% of transplant recipients) but serious cause of severe anemia that carries a dismal prognosis. Lymphoproliferative disorder, too may rarely rare cause anemia and it may respond to reduction of immunosuppression. Recipients of solid-organ transplants do not mount a significant increase in erythropoietin in response to anemia. In conclusion, though there are no data on the response of anemia to erythropoietin in liver transplant recipients, it appears to benefit other solid-organ-transplant recipients with anemia.
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Affiliation(s)
- Anurag Maheshwari
- Division of Gastroenterology & Hepatology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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23
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Rego F, Alcântara P, Buinho F, Araújo F, Santos JM, Parreira A, da Costa FL. Autologous peripheral stem cell transplantation for multiple myeloma in a patient with a 10 year-old kidney transplant: case report and clinical issues. Transplant Proc 2003; 35:1102-4. [PMID: 12947876 DOI: 10.1016/s0041-1345(03)00326-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- F Rego
- Renal Transplant Unit of Cruz Vermelha Portuguesa Hospital, R. Duarte Galvão, 54, 1549 008, Lisboa, Portugal
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24
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Chiang KY, Lazarus HM. Should we be performing more combined hematopoietic stem cell plus solid organ transplants? Bone Marrow Transplant 2003; 31:633-42. [PMID: 12692602 DOI: 10.1038/sj.bmt.1703952] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Both bone marrow and solid organ transplants (SOTs) can be life saving for a wide variety of diseases. We reviewed the literature and summarized the experiences of dual transplants. In total, 37 patients received a SOT for organ failure after a previous hematopoietic stem cell transplant. In all, 12 subjects received SOTs followed by a bone marrow transplant, while three patients received simultaneous SOTs and bone marrow transplants. Of these 52 patients, 37 were alive at the time of the original report at follow-up times ranging from 3 months to 8 years. A special registry for data collection may prove helpful for obtaining long-term follow-up data and providing outcome information that may improve future patient survival.
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Affiliation(s)
- K Y Chiang
- Division of Pediatric Hematology/Oncology, Children's Healthcare of Atlanta, GA 30322, USA
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