1
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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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2
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Ghandorah S, Alsawaf B, Alrefai W, Ghazwani A, Almusabi S. Role of HLA typing and chimerism analysis in post-liver transplantation GVHD in pediatrics: A systematic review. Pediatr Transplant 2022; 26:e14381. [PMID: 35979882 DOI: 10.1111/petr.14381] [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: 06/05/2022] [Revised: 07/30/2022] [Accepted: 08/06/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND GVHD is a well-documented complication after liver transplantation. GVHD occurs when donor immune cells mount a destructive immune response against host cells. The rarity of the GVHD complication and the nonspecific presentation of symptoms and histopathological features provide a diagnostic challenge. Therefore, diagnosis and initiation of treatment are often delayed. AIM In this systematic review, we assessed relevant literature to better understand the utilization of HLA typing and chimerism analysis in liver transplantation. We mainly focused on their importance in diagnosing GVHD incidence after liver transplantation. RESULTS A total of 18 articles reported 21 cases of GVHD after liver transplantation in pediatrics. Generally, there is a consensus on the advantage of HLA typing and chimerism analysis in confirming the diagnosis of GVHD after liver transplantation. However, there is an inconsistency in the timing and the application of the accurate HLA typing and chimerism analysis. CONCLUSION Further studies are required to assess the incidence of GVHD post-LT and to determine the impact of HLA typing and chimerism analysis in assessing the risk, early determination of GVHD incidence, and improving outcomes. This systematic review highlights the gap in the field of liver transplantation and calls for revisiting the guidelines to consider HLA typing and chimerism analysis in predicting GVHD before transplantation and diagnosing GVHD incidence after liver transplantation.
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Affiliation(s)
- Salim Ghandorah
- Department of Pathology and Laboratory Medicine, King Fahad Specialist Hospital - Dammam, Dammam, Saudi Arabia
| | | | - Weaam Alrefai
- Royal Commission Medical Center, Yanbu, Saudi Arabia
| | - Aisha Ghazwani
- Prince Sultan Military College of Health Sciences, Dhahran, Saudi Arabia
| | - Saleh Almusabi
- Prince Sultan Military College of Health Sciences, Dhahran, Saudi Arabia
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3
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Attas RAA, Bader RM, Mashhour M, AlQahtani ZA, Mohammed A, Qahtani M, Arain ZB, Faraidy N, Awaji M, Mohammed G, Alharbi HA, AlZahrani M, Aqool A, Salim G. Graft-versus-host disease after pediatric liver transplantation: A diagnostic challenge. Pediatr Transplant 2022; 26:e14205. [PMID: 34931754 DOI: 10.1111/petr.14205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/14/2021] [Accepted: 11/26/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Graft-versus-host disease (GVHD) is a rare but serious complication after pediatric liver transplantation (LTx). Early diagnosis is difficult due to nonspecific presenting symptoms and non-pathognomonic skin histopathological features. The aim of this article was to describe a case of pediatric GVHD after LTx and to review available data on pediatric GVHD highlighting the diagnostic difficulty. We also propose a diagnostic algorithm to improve the diagnostic capability and increase clinical awareness about this potentially fatal condition. METHODS We did a comprehensive literatures review on studies on GvHD following pediatric LTx between 1990 and February 2021, chimerism study by short tandem repeat (STR), HLA typing by sequence-specific oligonucleotide (SSO) method, and flowcytometry crossmatch. RESULTS Our search yielded 23 case reports. The most common clinical manifestations were fever and rash (91%) followed by diarrhea. Mortality rate was 36.8% mainly due to sepsis and organ failure. Diagnosis was challenging and chimerism study to confirm donor engraftment was performed on only half of the cases. Prevalence of "donor dominant HLA one-way matching" typically occurs in homozygous parents-to-child transplantation was 75% in cases with HLA testing. CONCLUSION So far, there are no available standard diagnostic criteria for GVHD following pediatric LTx. Recognition of multiple risk factors through proper laboratory assessment can predict the occurrence, and early chimerism study can confirm suggestive clinical manifestation. The strong likelihood of developing GVHD in "donor one-way HLA match" and the severe problems imposed by this complication may justify avoidance of HLA homozygous parent's donation.
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Affiliation(s)
- Rabab Ali Al Attas
- Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia.,Saudi Society of Bone Marrow Transplantation (SSBM), Riyadh, Saudi Arabia
| | - Razan M Bader
- Pediatric Liver Transplant, Liver Transplant Department, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
| | - Miral Mashhour
- Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
| | - Zuhoor A AlQahtani
- Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
| | - Amani Mohammed
- Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
| | - Masood Qahtani
- Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
| | - Zahid B Arain
- Liver Transplant, Liver Transplant Department, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
| | - Nadya Faraidy
- Dermatology, Medicine Department, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
| | - Mohammad Awaji
- Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
| | - Gamil Mohammed
- Dermatology, Medicine Department, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
| | - Hassan A Alharbi
- Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
| | - Mariam AlZahrani
- Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
| | - Amal Aqool
- Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
| | - Ghandorah Salim
- Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
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4
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Sato N, Marubashi S. How is transfusion-associated graft-versus-host disease similar to, yet different from, organ transplantation-associated graft-versus-host disease? Transfus Apher Sci 2022; 61:103406. [DOI: 10.1016/j.transci.2022.103406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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5
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Noguchi M, Shindo T, Yamada Y, Date H. T-cell chimerism prior to graft-versus-host disease. Eur J Cardiothorac Surg 2021; 60:194-196. [PMID: 33495782 DOI: 10.1093/ejcts/ezaa484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 12/07/2020] [Accepted: 12/15/2020] [Indexed: 01/19/2023] Open
Abstract
Graft-versus-host disease (GVHD), a serious complication of haematopoietic stem cell transplantation, can occur following solid organ transplantation. However, diagnosing solid organ transplantation-associated GVHD is difficult, and its risk factors are not fully understood. Here, we report a GVHD case in a 59-year-old woman with dermatomyositis-associated interstitial pneumonia, who took immunosuppressants including corticosteroids before receiving right lung transplantation from a 13-year-old brain-dead male donor. She developed systemic erythema with desquamation and pancytopenia by day 20. Mixed chimerism with donor- and recipient-type cells in the bone marrow and skin led to the diagnosis of GVHD. Corticosteroid pulse therapy reduced the symptoms and decreased donor-type cell percentage. On day 50, the patient developed donor lung injury and was diagnosed with acute rejection, which was treated using steroid pulse therapy again. Although the granulocytes were recipient type, donor chimerism of peripheral blood T cells exacerbated on day 68. Subsequent deterioration of liver function and pulmonary injury in the patient's own lung led to the diagnosis of relapsing GVHD. The patient died of multiple organ failure despite treatment with anti-thymocyte globulin. Thus, repeated steroid pulse therapy and age difference between donors and recipients may predispose to GVHD and T-cell mixed chimerism can be an important diagnostic indicator of GVHD.
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Affiliation(s)
- Misa Noguchi
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takero Shindo
- Department of Hematology/Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yosuke Yamada
- Department of Diagnostic Pathology, Kyoto University Hospital, Kyoto, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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6
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Ghandorah SS, Alwosaibai K. Post-liver transplantation GVHD: time to consider histocompatibility testing. JOURNAL OF LIVER TRANSPLANTATION 2021. [DOI: 10.1016/j.liver.2021.100021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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7
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Kim KJ, Lee TB, Yang KH, Ryu JH, Choi BH, Lee HJ, Lee SM, Kim IS. Temporary Cessation of Immunosuppression for Infection May Contribute to the Development of Graft-vs-Host Disease After ABO-Incompatible Living Donor Liver Transplantation: A Case Report. Transplant Proc 2019; 51:3136-3139. [PMID: 31611115 DOI: 10.1016/j.transproceed.2019.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 07/28/2019] [Indexed: 11/27/2022]
Abstract
Graft-vs-host disease (GVHD) after liver transplantation is a rare complication with a high mortality rate. A complex interplay between donor and recipient immunity plays a role in the development of GVHD. Infection following liver transplantation is one of the most common complications in a recipient of an organ transplant who is immunosuppressed. On clinical signs of infection, the immune reaction of the recipient can be reconstituted by withdrawal of immunosuppression in order to help combat infection. However, the discontinuation of immunosuppression could restore the donor's immune activity rather than that of the recipient. There is little information available as to whether the discontinuation of immunosuppression for severe infection could contribute to the development of GVHD in a patient who underwent ABO-incompatible (ABO-I) living donor liver transplantation (LDLT). Herein, we present a unique case of GVHD following ABO-I LDLT, for which the cessation of immunosuppression could be responsible.
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Affiliation(s)
- Keun Ju Kim
- Department of Laboratory Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Tae Beom Lee
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Kwang Ho Yang
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Je Ho Ryu
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Byung Hyun Choi
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Hyun-Ji Lee
- Department of Laboratory Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.
| | - Sun-Min Lee
- Department of Laboratory Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - In-Suk Kim
- Department of Laboratory Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
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8
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Chen W, Ma T, Bai X, Zhang X, Li G, Lao M, Liang T. Acute Graft-vs-Host Disease After Liver Transplantation in a Patient Presenting With Neurogenic Symptoms as the Single Primary Manifestation: A Case Report. Transplant Proc 2018; 50:4028-4032. [DOI: 10.1016/j.transproceed.2018.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 05/23/2018] [Indexed: 12/24/2022]
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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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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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11
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Green T, Hind J. Graft-versus-host disease in paediatric solid organ transplantation: A review of the literature. Pediatr Transplant 2016; 20:607-18. [PMID: 27198497 DOI: 10.1111/petr.12721] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2016] [Indexed: 12/23/2022]
Abstract
GvHD is a rare and serious complication of organ transplantation. The literature is sparse following solid organ transplantation. The aim of this report was to review the literature of GvHD in paediatric solid organ transplantation. We searched PubMed for English-language full-text manuscripts between 1990 and 2015 for eligible studies. A total of 28 publications were found pertaining to paediatric GvHD following solid organ transplantation. GvHD had a mean incidence of 11% (range 8.3-13.4%) following SBTx and 1.5% following liver transplantation. Where described, the most common sites for presentation of GvHD were the skin (87%), the native GI tract (43%), the lungs (7%), the eyes (4%), HA (4%), and the kidneys (1%). Diagnosis was confirmed with biopsy (93%) and/or chimerism (41%). Treatments used include steroids (80%), of which 75% showed partial or complete resolution. Mortality was 33.3% (range 0-100%). Novel therapies include ECP and MSC therapy. GvHD is a rare but serious disease with high mortality. Novel therapies may offer hope in the future, but currently there is limited evidence for their efficacy in the context of intestinal or liver transplantation.
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Affiliation(s)
- Thomas Green
- King's College London - GKT School of Medical Education, London, UK
| | - Jonathan Hind
- King's College Hospital - Paediatric Liver, GI and Nutrition Centre, London, UK
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12
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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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13
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Sanz-Bueno J, Pérez-Rial G, Castellanos M, Vanaclocha F. Lichenoid Graft-vs-Host Disease With Exclusively Cutaneous Involvement After Liver Transplant. ACTAS DERMO-SIFILIOGRAFICAS 2014. [DOI: 10.1016/j.adengl.2013.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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14
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Sanz-Bueno J, Pérez-Rial G, Castellanos M, Vanaclocha F. Lichenoid graft-vs-host disease with exclusively cutaneous involvement after liver transplant. ACTAS DERMO-SIFILIOGRAFICAS 2013; 105:198-200. [PMID: 23809586 DOI: 10.1016/j.ad.2013.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Revised: 03/26/2013] [Accepted: 04/01/2013] [Indexed: 11/20/2022] Open
Affiliation(s)
- J Sanz-Bueno
- Servicio de Dermatología, Hospital Universitario 12 de Octubre, Madrid, España.
| | - G Pérez-Rial
- Servicio de Medicina del Aparato Digestivo, Hospital Universitario Gregorio Marañón, Madrid, España
| | - M Castellanos
- Servicio de Dermatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - F Vanaclocha
- Servicio de Dermatología, Hospital Universitario 12 de Octubre, Madrid, España
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15
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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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16
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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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17
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Shin CR, Nathan J, Alonso M, Yazigi N, Kocoshis S, Tiao G, Davies SM. Incidence of acute and chronic graft-versus-host disease and donor T-cell chimerism after small bowel or combined organ transplantation. J Pediatr Surg 2011; 46:1732-8. [PMID: 21929982 DOI: 10.1016/j.jpedsurg.2011.04.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Revised: 04/18/2011] [Accepted: 04/18/2011] [Indexed: 10/17/2022]
Abstract
PURPOSE Graft-versus-host disease (GVHD) after organ transplantation is a rare but life-threatening complication with very high mortality. METHODS A retrospective review was performed of all patients undergoing small bowel or combined organ transplantation at a single institution during 2003 to 2009. Patients with donor T-cell chimerism were analyzed in detail for development of GVHD. RESULTS Thirty-two patients were included in the study. Of 32 patients, 11 (34%) had donor T-cell chimerism (range, 0%-53%) studies performed; 7 (64%) of those 11 patients demonstrated clinical features of GVHD. All patients who demonstrated GVHD had detectable donor T-cell chimerism. All patients with GVHD presented with skin involvement. Graft-versus-host disease responded to increased immune suppression therapy. Mortality was 43% (3/7) among patients with GVHD and was caused by multiorgan failure and sepsis in all cases. CONCLUSION Acute and chronic GVHD were observed frequently after combined solid organ transplantation and were associated with significant mortality and morbidity. Alloreactive donor T cells cotransplanted with the organ likely play a role in the pathophysiology because levels of donor-derived T-cell chimerism correlated with the clinical course of GVHD.
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Affiliation(s)
- Chu Ri Shin
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital and Medical Center, Cincinnati, OH 45229, USA
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18
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Graft-versus-host disease after intestinal and multivisceral transplantation. Transplantation 2011; 91:219-24. [PMID: 21076376 DOI: 10.1097/tp.0b013e3181ff86ec] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Graft-versus-host-disease (GVHD) is a rare complication but carries a high mortality after transplantation. We retrospectively evaluated the incidence, risk factors and impact of this complication on the survival outcome of intestinal transplantation at a single center. METHODS 241 patients who underwent intestinal transplantation between March 1994 and July 2007 were analyzed for evidence of GVHD. A diagnosis of GVHD was based on clinical presentations and confirmed by histological findings. RESULTS Of the 241 patients, 22 (9.1%) were diagnosed as GVHD. The median time of GVHD onset was 75 days (range, 14-1,408). The incidence of GVHD was significantly higher in young children than in adults (13.2 versus 4.4%, P = 0.05). The multivisceral graft recipients were more likely to develop GVHD compared with those of isolated small bowel (12.4% versus 4.6%, P = 0.05). The presence of recipient splenectomy was significantly associated with the incidence of GVHD (P = 0.03). The inclusion of the spleen in the multivisceral grafts tended to be at an increased risk of GVHD compared with the group without the spleen transplant (12.3% versus 7.9%, P = 0.43). A total of 16 patients with GVHD died during the entire follow-up. Infection was the leading cause of death in 55% patients. CONCLUSIONS GVHD is a fatal and progressive complication of small bowel transplantation. Younger children, multivisceral graft recipients, and particularly those with splenectomy are at high risk of developing GVHD after transplantation.
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19
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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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20
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Avoiding pitfalls: what an endoscopist should know in liver transplantation--part II. Dig Dis Sci 2009; 54:1386-402. [PMID: 19085103 DOI: 10.1007/s10620-008-0520-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2007] [Accepted: 08/27/2008] [Indexed: 02/07/2023]
Abstract
Over the last decade the number of patients undergoing transplantation has increased. At the same time, effective peri- and postoperative care and better surgical techniques have resulted in greater numbers of recipients achieving long-term survival. Identification and effective management in the form of adequate treatment is essential, since any delay in diagnosis or treatment may result in graft loss or serious threat to patient's life. Various aspects of endoscopic findings that can be commonly encountered among liver transplant recipients are discussed herein. Topics include: persistent and/or recurrent esophageal varices, reflux, Candida or cytomegalovirus (CMV) esophagitis, esophageal neoplasms, posttransplant peptic ulcer, biliary complications, posttransplant lymphoproliferative disorder (PTLD), Kaposi's sarcoma, CMV colitis and inflammatory bowel disease, colonic neoplasms, Clostridium difficile infection, and graft versus host disease (GVHD).
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21
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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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22
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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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23
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Alexander SI, Smith N, Hu M, Verran D, Shun A, Dorney S, Smith A, Webster B, Shaw PJ, Lammi A, Stormon MO. Chimerism and tolerance in a recipient of a deceased-donor liver transplant. N Engl J Med 2008; 358:369-74. [PMID: 18216357 DOI: 10.1056/nejmoa0707255] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Complete hematopoietic chimerism and tolerance of a liver allograft from a deceased male donor developed in a 9-year-old girl, with no evidence of graft-versus-host disease 17 months after transplantation. The tolerance was preceded by a period of severe hemolysis, reflecting partial chimerism that was refractory to standard therapies. The hemolysis resolved after the gradual withdrawal of all immunosuppressive therapy.
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Affiliation(s)
- Stephen I Alexander
- Centre for Kidney Research, Children's Hospital at Westmead and the Department of Paediatrics and Child Health, University of Sydney, Sydney, Australia
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24
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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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25
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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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26
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Weinstein A, Dexter D, KuKuruga DL, Philosophe B, Hess J, Klassen D. Acute Graft-versus-Host Disease in Pancreas Transplantation: A Comparison of Two Case Presentations and a Review of the Literature. Transplantation 2006; 82:127-31. [PMID: 16861952 DOI: 10.1097/01.tp.0000225832.47130.10] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
As a complication of solid organ transplantation, acute graft-versus-host disease (GVHD) is most associated with small bowel and liver transplants. We present two cases of acute GVHD following pancreas transplantation. Case 1 was a 27-year-old female who underwent cadaveric pancreas transplant 9 months after a successful live donor kidney transplant. Case 2 was a 38-year-old male who received a simultaneous cadaveric pancreas and live donor kidney transplant. Both patients presented within 30 days of transplant with nonspecific symptoms. Rejection and infection were ruled out. Both subjects had progressive decline in mentation associated with pancytopenia and hyperbilirubinemia. Rash was not present until late in their hospital course. Skin biopsies demonstrated mixed chimerism with pancreas donor DNA diagnostic of GVHD. Acute GVHD is a rare, often fatal, complication of pancreas transplantation, and its presentation appears to differ from acute GVHD associated with stem cell transplantation.
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Affiliation(s)
- Adam Weinstein
- Department of Medicine, Division of Nephrology, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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27
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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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28
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Stein J, Mor E. Dueling lymphocytes: picking the winner. Transplantation 2004; 78:1719-20. [PMID: 15614143 DOI: 10.1097/01.tp.0000144267.78611.6e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Jerry Stein
- Bone Marrow Transplantation Unit, Department of Pediatric Oncology, Schneider's Children Medical Center, Tel-Aviv University, Israel
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29
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Key T, Taylor CJ, Bradley JA, Taylor AL. Recipients Who Receive a Human Leukocyte Antigen-B Compatible Cadaveric Liver Allograft are at High Risk of Developing Acute Graft-versus-Host Disease. Transplantation 2004; 78:1809-11. [PMID: 15614155 DOI: 10.1097/01.tp.0000145523.08548.48] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Acute graft-versus-host disease (GvHD) is an uncommon but often fatal complication after orthotopic liver transplantation (OLT). To determine whether there is an association between human leukocyte antigen (HLA) matching and the development of GvHD after cadaveric OLT, we undertook a retrospective, single-center analysis of 412 consecutive adult recipients where HLA typing data was available. Seven (1.7%) recipients developed acute GvHD, and six died from their disease. Donor compatibility at HLA-B but not at HLA-A or -DR was identified as a significant risk factor for the development of GvHD. Of 14 recipients with no HLA-B mismatches, 3 (21%) developed GvHD (odds ratio 27, P<0.001). Conversely, of 262 recipients mismatched at both HLA-B loci, only 1 (0.4%) developed GvHD (odds ratio 0.09, P<0.01). Our findings suggest that patients receiving a liver allograft with no HLA-B mismatched antigens are at increased risk of developing GvHD.
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Affiliation(s)
- Tim Key
- Tissue Typing Laboratory, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, UK
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30
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Taylor AL, Gibbs P, Bradley JA. Acute graft versus host disease following liver transplantation: the enemy within. Am J Transplant 2004; 4:466-74. [PMID: 15023138 DOI: 10.1111/j.1600-6143.2004.00406.x] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
This article reviews acute graft vs. host disease (GVHD) as a complication of orthotopic liver transplantation (OLT). The incidence, presentation, clinical course and outcome of GVHD after OLT are summarized and the pathogenesis is discussed, drawing parallels with GVHD after allogeneic haematopoietic stem cell transplantation. Risk factors for GVHD after OLT are examined and the potential role of donor lymphocyte macrochimerism in the recipient peripheral blood as a diagnostic aid for GVHD is discussed. Finally, treatment of GVHD after OLT is reviewed with particular emphasis on the potential role of some of the newer biological agents.
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Affiliation(s)
- Anna L Taylor
- Department of Surgery, University of Cambridge School of Clinical Medicine, Cambridge, UK
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31
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Soejima Y, Shimada M, Suehiro T, Hiroshige S, Gondo H, Takami A, Yasue S, Maehara Y. Graft-versus-host disease following living donor liver transplantation. Liver Transpl 2004; 10:460-4. [PMID: 15004778 DOI: 10.1002/lt.20101] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [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 the most common and well-known cause of morbidity and mortality following allogeneic bone marrow transplantation. Sporadic cases have been reported after cadaveric donor liver transplantation with usually fatal outcomes, however, the actual incidence and the characteristics of GVHD after living donor liver transplantation (LDLT) remain unknown. We herein report a person who developed fatal GVHD following LDLT and discuss the applicability of an HLA-homozygous donor to an HLA-haploidentical recipient. A 48-year-old male underwent LDLT for unresectable hepatocellular carcinoma with alcoholic liver cirrhosis. The donor was his 20-year-old son whose pretransplant HLA typing was homozygous at all loci. GVHD occurred 35 days after LDLT and was characterized by fever, diarrhea, maculopapular rash, and leukopenia, which led to the development of fatal pneumonia. We identified 4 cases of GVHD after LDLT in Japan and 1 in the United States, all associated with the use of an HLA-homozygous donor. The use of an HLA homozygous donor which results in a complete 1-way donor-recipient HLA match carries an extremely high risk of developing GVHD after LDLT. Therefore, it is possible that LDLT should be ruled out for such donors. A pretransplant work-up of the HLA type in both the donors and recipients is therefore imperative before determining the indications for LDLT.
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Affiliation(s)
- Yuji Soejima
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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32
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Astarcioglu I, Karademir S, Gülay H, Bora S, Astarcioglu H, Kavukcu S, Türkmen M, Soylu A. Primary hyperoxaluria: simultaneous combined liver and kidney transplantation from a living related donor. Liver Transpl 2003; 9:433-6. [PMID: 12682898 DOI: 10.1053/jlts.2003.50072] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Primary hyperoxaluria type 1 (PH1) is a rare inherited metabolic disorder in which deficiency of the liver enzyme AGT leads to renal failure and systemic oxalosis. Timely, combined cadaveric liver-kidney transplantation (LKT) is recommended for end-stage renal failure (ESRF) caused by PH1; however, the shortage of cadaveric organs has generated enthusiasm for living-related transplantation in years. Recently, successful sequential LKT from the same living donor has been reported in a child with PH1. We present a sister-to-brother simultaneous LKT in a pediatric patient who suffered from PH1 with ESRF. Twelve months after transplantation, his daily urine oxalate excretion was decreased from 160 mg to 19.5 mg with normal liver and renal allograft functions. In addition to the well-known advantages of living organ transplantation, simultaneous LKT may facilitate early postoperative hemodynamic stability and may induce immunotolerance and allow for low-dose immunosuppression.
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Affiliation(s)
- Ibrahim Astarcioglu
- General Surgery, Transplantation Unit, Dokuz Eylul University, School of Medicine, Inciralti, Izmir, Turkey
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33
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Nemoto T, Kubota K, Kita J, Shimoda M, Rokkaku K, Tagaya N, Fujiwara T, Sunakawa M. Unusual onset of chronic graft-versus-host disease after adult living-related liver transplantation from a homozygous donor. Transplantation 2003; 75:733-6. [PMID: 12640319 DOI: 10.1097/01.tp.0000053401.91094.ca] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Graft-versus-host disease (GVHD) is a rare complication that occurs after living-related liver transplantation (LRLT). This condition usually occurs early after transplantation and is fatal. Although one-way matching between a human leukocyte antigen (HLA)-homozygous donor and a haploidentical recipient has been shown to be a significant risk factor for the development of acute GVHD, chronic GVHD has not been clarified. A 50-year-old woman underwent LRLT for primary biliary cirrhosis with her 32-year-old HLA-homozygous son as the donor. The patient developed chronic GVHD 114 days posttransplant, presenting with a skin rash only. Her atypical onset included neither fever nor gastrointestinal symptoms. The patient responded to corticosteroid therapy and is now doing well at home. Careful donor selection and HLA matching before LRLT should be performed to prevent GVHD. However, the risks associated with grafts from homozygous donors may be unavoidable at present because of the shortage of cadaveric donors in Japan.
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Affiliation(s)
- Takehiko Nemoto
- Liver Transplant Team, Department of Surgery, Dokkyo University School of Medicine, Tochigi, Japan.
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34
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Smith DM, Agura E, Netto G, Collins R, Levy M, Goldstein R, Christensen L, Baker J, Altrabulsi B, Osowski L, McCormack J, Fichtel L, Dawson DB, Domiati-Saad R, Stone M, Klintmalm G. Liver transplant-associated graft-versus-host disease. Transplantation 2003; 75:118-26. [PMID: 12544883 DOI: 10.1097/00007890-200301150-00022] [Citation(s) in RCA: 142] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Graft-versus-host disease (GVHD) is an important, underdiagnosed cause of mortality associated with liver transplantation. We identified 12 cases of GVHD among 1,082 liver transplantations performed in patients at our institution between 1991 and 1998. Patients typically developed fever, skin rash, diarrhea, or pancytopenia within 2 to 6 weeks after their transplant. Treatment generally involved increased immune suppression and hematopoietic cytokines (granulocyte colony stimulating factor, granulocyte monocyte colony stimulating factor); however, all but one patient died, most often from sepsis. Early in its course, GVHD was difficult to distinguish from cytomegalovirus disease or drug reactions. The diagnosis was confirmed by demonstration of substantial donor lymphoid chimerism. METHODS To identify risk factors for severe GVHD, a retrospective analysis was performed comparing index cases with the rest of the cases in our institutional experience. RESULTS Closely matched human leukocyte antigen recipients, those older than 65 years, and recipients with donors more than 40 years younger were at higher risk for GVHD. One case occurred in a patient with a congenital immunodeficiency. CONCLUSIONS Liver transplant-associated GVHD is a progressive and fatal disease. Future approaches should focus on prevention and might include avoidance of closely matched human leukocyte antigen donors, treatment of the donor to reduce the number of lymphocytes, or reduction of immunosuppression in the early posttransplant period.
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Affiliation(s)
- Douglas M Smith
- Transplant Immunology Laboratory, Baylor University Medical Center, Dallas, TX, USA.
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35
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Kasahara M, Kiuchi T, Uryuhara K, Uemoto S, Fujimoto Y, Ogura Y, Oike F, Kaihara S, Egawa H, Tanaka K. Role of HLA compatibility in pediatric living-related liver transplantation. Transplantation 2002; 74:1175-80. [PMID: 12438966 DOI: 10.1097/00007890-200210270-00020] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Human leukocyte antigen (HLA) matching is, at present, not used for the allocation of cadaveric hepatic allografts because the liver is generally believed to be less susceptible to HLA-mediated rejection. However, the exact role of HLA compatibility in the long-term outcome of liver transplantation is not yet clearly defined. One of the advantages of living-related liver transplantation (LRLT) could be a better histocompatibility between donor and recipient. This study aimed at an assessment of the influence of HLA compatibility in a large series of LRLTs. METHODS A total of 321 pediatric patients who underwent ABO-identical or ABO-compatible primary LRLT from the parental donors in the period between June 1990 and August 2000 were involved in the study. Graft survival, rejection episodes, and immunosuppression were evaluated from the viewpoint of HLA compatibility. RESULTS The overall 1- and 5-year graft survivals were 85.7% and 84.1%, respectively. The cumulative 5-year graft survivals in HLA 0-, 1-, 2- and 3-mismatch groups (A, B, and DR) were 100% (n=10), 78.9% (n=19), 86.2% (n=87), and 82.9% (n=205), respectively (P=0.525). The overall incidence of rejection during the follow-up period (median 66 months, range 16-139 months) was 46.1%. No significant difference was found in the incidence of rejection and rejection-free survival among the four groups. However, steroid-resistant rejection that necessitated OKT3 treatment (n=6) and chronic rejection (n=2) were recognized only in the 3-mismatch group. The whole-blood trough level of tacrolimus and the duration of steroid administration were not significantly different among the groups. The rate of the patients who succeeded in withdrawal from immunosuppression was also similar among the groups. However, the trough level of tacrolimus needed for maintenance of an acceptable liver function test during the chronic phase tended to be lower in well-matched pairs, and a high percentage of immunosuppressant-free patients were found in the 0-mismatch group. Fatal graft-versus-host disease developed in one patient with a complete one-way HLA-matched transplant. CONCLUSION We could not find any supportive evidence of beneficial effects of HLA-matching in pediatric LRLT. The potential benefit of HLA-matching for the reduction protocol for immunosuppressants may play a role in the withdrawal program. It appears unnecessary to pay attention to HLA compatibility in donor selection in LRLT, except for one-way HLA matching, or to adjust immunosuppression according to HLA compatibility.
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Affiliation(s)
- Mureo Kasahara
- Organ Transplant Unit, Department of Transplant Surgery, Kyoto University Hospital, 54 Kawara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan. mureo@kuhp. kyoto-u.ac.jp
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36
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Lehner F, Becker T, Sybrecht L, Lück R, Schwinzer R, Slateva K, Blasczyk R, Hertenstein B, Klempnauer J, Nashan B. Successful outcome of acute graft-versus-host disease in a liver allograft recipient by withdrawal of immunosuppression. Transplantation 2002; 73:307-10. [PMID: 11821752 DOI: 10.1097/00007890-200201270-00030] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Graft-versus-host disease (GVHD) after liver transplantation is uncommon, and the outcome is almost always fatal. Since 1987, about 30 cases have been described, and patient survival is mostly exceptional. METHODS A 29-year-old man underwent retransplantation due to chronic cholestatic syndrome, 5 years after his first liver transplantation. Indication for the first liver transplantation was acute liver failure caused by exsiccosis. After the second transplantation, the patient had an initially uneventful course, developing thrombocytopenia at day 21 followed by skin rash and septic complications. Diagnosis of acute GVHD was made by using serological techniques for HLA-A and HLA-DRB and subsequently by fluorogenic sequence-specific primed polymerase chain reaction. In addition, donor lymphocytes were marked by immunohistochemical methods via biopsies of the skin. Immunosuppressive therapy was withdrawn to allow the patient's own immune system to eliminate donor cells. RESULTS By withdrawing the immunosuppressive therapy, clinical and morphological signs of GVHD vanished. The patient is doing well without recurrence 13 months after transplantation. CONCLUSION Withdrawal of immunosuppressive therapy is a promising approach in the treatment of acute GVHD to allow the patient's immune system to reconstitute itself, reject offending lymphocytes, and avoid lethal septic complications.
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Affiliation(s)
- F Lehner
- Klinik für Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Germany
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Stachel D, Schmid I, Lang T, Haas RJ, Otte JB. Double bone marrow transplantation for severe aplastic anemia after orthotopic liver transplantation: implications for clinical management and immune tolerance. Transpl Int 2002. [DOI: 10.1111/j.1432-2277.2002.tb00096.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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38
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Au WY, Lo CM, Hawkins BR, Ma ES, Lie AK, Kwong YL. Evans' syndrome complicating chronic graft versus host disease after cadaveric liver transplantation. Transplantation 2001; 72:527-8. [PMID: 11502987 DOI: 10.1097/00007890-200108150-00028] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute graft versus host disease (GVHD) occurred in a patient after cadaveric liver transplantation from an HLA disparate donor. Immunosuppression resulted in a remission, but chronic GVHD with a scleroderma-like syndrome ensued. This was further complicated by immune hemolytic anemia and thrombocytopenia (Evan's syndrome). Semi-quantitative microsatellite analysis of circulating lymphoid cells showed that T cells were predominantly of donor origin, thereby explaining the chronic GVHD. The marrow hematopoietic cells remained recipient, so that the immune cytopenias were expected to be alloimmune in nature. However, the red cell antibodies were shown to have anti-C and anti-e specificity, with both the donor (R1R1) and recipient (R1r) possessing the C and e antigens. Therefore, the immune hemolysis might be considered both alloimmune and autoimmune. The patient finally died of sepsis. This case illustrates that chronic GVHD due to stable donor T cell engraftment may rarely occur in liver transplantation despite HLA disparity. Immunosuppression may result in dysregulation of T cell functions, leading to alloimmune and autoimmune problems.
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Affiliation(s)
- W Y Au
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Pokfulam Road, Hong Kong
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Dunn SP, Krueger LJ, Butani L, Punnett H. Late onset of severe graft-versus-host disease in a pediatric liver transplant recipient. Transplantation 2001; 71:1483-5. [PMID: 11391240 DOI: 10.1097/00007890-200105270-00022] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
We report the management of a patient with the late onset of chronic graft-versus-host disease (GVHD) after orthotopic liver transplantation. GVHD is a rare complication of solid organ transplants that usually presents early after transplantation and is fatal in the majority of cases. Our patient differs from the typical patient with GVHD in that the onset of her disease was very late. Although most treatment to date consisted of an increase in immunosuppressive therapy, our patient showed an excellent response to a reduction. This resulted in the abatement of the symptoms of GVHD and the preservation of her allograft function.
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Affiliation(s)
- S P Dunn
- Division of Solid Organ Transplantation, Department of Surgery, 1600 Rockland Road, Wilmington, DE 19899, USA
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40
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Abstract
The phenomenon of microchimerism and its relationship to long-term graft tolerance is an area of active study. The ability to establish a tolerant state has been enhanced with current immunosuppressive drugs and emerging therapies such as donor HPC infusions. An undesirable outcome of host-donor WBC interaction is GVHD. GVHD is a rare complication reported most frequently in liver transplantation. Two cases of GVHD reported in recipients of organs from donors homozygous for a shared HLA haplotype would support a policy of avoiding the use of these donors. TA-GVHD is very rare in solid organ transplant recipients, with only four published cases; only two had convincing supportive evidence and one of these had an underlying hematologic abnormality. These few cases do not support a policy of routine irradiation of cellular blood components for all solid organ transplant recipients. The use of donor HPC infusions to enhance chimerism and graft tolerance has increased the number of GVHD cases observed (usually mild) and decreased the severity and number of rejection episodes. The long-term effects of donor HPC infusions on graft survival is under investigation.
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Affiliation(s)
- D J Triulzi
- Department of Pathology, University of Pittsburgh Medical Center and the Institute for Transfusion Medicine, Pittsburgh, PA 15213, USA.
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Au WY, Ma SK, Kwong YL, Ng IO, Hawkins BR, Wan TS, Liu CL, Fan ST, Lo CM. Graft-versus-host disease after liver transplantation: documentation by fluorescent in situ hybridisation and human leucocyte antigen typing. Clin Transplant 2000; 14:174-7. [PMID: 10770425 DOI: 10.1034/j.1399-0012.2000.140213.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Graft-versus-host disease (GVHD) after liver transplantation is uncommon and the outcome is often fatal. A firm diagnosis of GVHD is difficult because the clinical triad of skin rash, marrow failure and diarrhoea can be indistinguishable from drug reaction or viral infection, and the presence of donor lymphocyte chimerism is not specific. We describe a case of severe GVHD in a female patient after liver transplantation from a male cadaveric donor. Skin biopsy showed characteristic changes of GVHD. Using Y-chromosome-specific fluorescent in situ hybridisation (FISH), male lymphocytes were demonstrated in 10% of marrow cells and in 90% of lymphocytes infiltrating the dermal epidermal junction. Donor human leucocyte antigens (HLAs) were detected in the peripheral blood, buccal mucosa and skin by polymerase chain reaction. The GVHD subsided with steroid and anti-thymocyte globulin, but recurred on tailing off of treatment. Despite maximum supportive therapy, including random donor leucocyte infusion, and marrow infusion from a HLA-identical sibling, the patient succumbed to sepsis. Our results showed the utility of combining morphological features with molecular techniques using FISH and HLA typing in confirming a diagnosis of GVHD.
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Affiliation(s)
- W Y Au
- Department of Medicine, The University of Hong Kong Medical Centre, Queen Mary Hospital, China
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Pinna AD, Weppler D, Berho M, Masetti M, DeFaria W, Kato T, Thompson J, Ricordi C, Tzakis AG. Unusual presentation of graft-versus-host disease in pediatric liver transplant recipients: evidence of late and recurrent disease. Pediatr Transplant 1999; 3:236-42. [PMID: 10487286 DOI: 10.1034/j.1399-3046.1999.00043.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Graft-versus-host disease (GvHD) is a multi-organ disease caused by mature donor T cells that are activated by alloantigens expressed by the host antigen-presenting cells. GvHD has been reported after solid organ transplantation with two principal presentations: humoral and cellular. In the cellular type of GvHD after liver transplantation the symptoms are identical to the GvHD after bone marrow transplant, except that the liver is spared because it lacks host antigens. We have described three cases of intestinal GvHD after pediatric liver transplant with an unusual recurrent late presentation in two patients. Two patients were female, and their age at the time of transplant was 8 and 9 months, respectively, and one was an 8-month-old male. They all received reduced liver allografts of identical blood type from three different donors. One patient received two doses of donor bone marrow cell infusion. Two patients received double immunosuppressive therapy constituted by tacrolimus at a dose of 0.05 mg/kg p.o. b.i.d. and steroids 10 mg p.o. daily. One patient received a triple drug immunosuppression with tacrolimus (0.05 mg/kg p.o. b.i.d.), steroids (10 mg p.o. daily) and mycophenolate mofetil (125 mg p.o. b.i.d.). Diagnosis of intestinal GvHD was confirmed histologically on intestinal biopsies performed at the time of presentation of the clinical symptoms or at autopsy.
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Affiliation(s)
- A D Pinna
- Department of Surgery, University of Miami, Florida, USA.
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Merhav HJ, Landau M, Gat A, Gazit E, Baratz M, Bialy-Golan A, Konikof F, Bril S, Nakache R. Graft versus host disease in a liver transplant patient with hepatitis B and hepatocellular carcinoma. Transplant Proc 1999; 31:1890-1. [PMID: 10371987 DOI: 10.1016/s0041-1345(99)00141-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- H J Merhav
- Department of Surgery B, Tel Aviv Medical Center, Tel Aviv University, Sackler School of Medicine, Petach Tikvah, Israel
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Okasha KM, Al-Tweigeri TA, Jurado AV, Shoker AS. Analysis of the relationship between chimerism and the allgeneic humoral response. Transplantation 1998; 66:1028-34. [PMID: 9808487 DOI: 10.1097/00007890-199810270-00011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Persistence of antigens has been suggested to play a role in two opposing immunological phenomena: tolerance and memory. Therefore, we studied the impact of chimerism on alloreactive antibody (allo-Ab) production in kidney transplant patients. METHODS Thirty-five female renal transplant recipients of male donor organs were classified into the following groups: group 1, 13 sensitized uremic patients on dialysis; group 2, 5 nonsensitized uremic patients on dialysis; group 3, six sensitized patients experiencing graft rejection (3 acute vascular, 1 acute cellular, and 2 chronic); and group 4, 11 nonsensitized with functioning allografts (9 with good function, 1 with acute cellular rejection, and 1 with chronic rejection). Mean duration of dialysis after graft failure was similar in groups 1 (56+/-29.7 months) and 2 (41.8+/-42.4 months), as was dialysis efficiency. Chimerism was measured indirectly in the peripheral blood lymphocytes by polymerase chain reaction amplification of a specific Y chromosome DNA gene sequence with a detection sensitivity limit of 1 male cell per 1 million female cells. Allo-Ab production was measured by the PRA-STAT enzyme-linked immunosorbent assay (Sangstat) method. RESULTS Chimerism was observed in 60% of groups 1 and 2, 83% of group 3, and 82% of group 4. Among all groups, graft existence, irrespective of its function, positively predicted chimerism in 92% with a sensitivity of 88% and a specificity of 78%. In group 3, all three patients with acute vascular rejection had chimerism and donor-specific allo-Abs. In group 4, eight of the nine patients with no rejection had chimerism. CONCLUSION Chimerism relates to persistence of allogeneic stimulus irrespective of its function. Chimerism did not confer protection against allo-Ab production or vascular rejection, and its existence was not crucial for sustenance of allo-Ab production.
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Affiliation(s)
- K M Okasha
- Department of Medicine, Royal University Hospital, Saskatoon, Saskatchewan, Canada
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Abstract
A pronounced similarity exists between liver allograft rejection and graft-versus-host disease (GVHD) in the damage and eventual destruction of small intrahepatic bile ducts. Although an immunologic reaction has an important role, precisely identifying the target antigens or reason for persistence of the immune response has been difficult. An important difference between GVHD and liver rejection is the development of obliterative arteriopathy only in rejection. The three main histopathologic features of acute rejection are a predominantly mononuclear but mixed portal inflammation, subendothelial inflammation of portal or terminal hepatic veins (or both), and bile duct inflammation and damage. In acute rejection, a controversial issue is determining when therapeutic intervention is needed. The recommended approach is to base treatment on a combination of histopathologic changes and liver injury or dysfunction. Chronic rejection, which usually does not occur before 2 months after transplantation, is characterized by two main histopathologic features: (1) damage and loss of small bile ducts and (2) obliterative arteriopathy. Acute GVHD begins within the first month after transplantation and most commonly involves the skin, gastrointestinal tract, and liver, whereas chronic GVHD usually develops more than 80 to 100 days after liver transplantation and affects 30 to 50% of long-term survivors. Recognition of the early, cellular stages of chronic GVHD is important in preventing irreversible damage.
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Affiliation(s)
- A J Demetris
- Division of Transplantation Pathology, University of Pittsburgh Medical Center, Pennsylvania, USA
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