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Abreu P, Manzi J, Vianna R. Innovative surgical techniques in the intestine and multivisceral transplant. Curr Opin Organ Transplant 2024; 29:88-96. [PMID: 37902277 DOI: 10.1097/mot.0000000000001098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
PURPOSE OF REVIEW This timely review delves into the evolution of multivisceral transplantation (MVT) over the past six decades underscoring how advancements in surgical techniques and immunosuppression have driven transformation, to provide insight into the historical development of MVT, shedding light on its journey from experimentation to a valuable clinical approach. RECENT FINDINGS The review presents contemporary enhancements in surgical methods within the context of intestinal transplantation. The versatility of MVT is emphasized, accommodating diverse organ combinations and techniques. Both isolated intestinal transplantation (IIT) and MVT have seen expanded indications, driven by improved parenteral nutrition, transplantation outcomes, and surgical innovations. Surgical techniques are tailored based on graft type, with various approaches for isolated transplantation. Preservation strategies and ostomy techniques are also covered, along with graft assessment advancements involving donor-specific antibodies. SUMMARY This review's findings underscore the remarkable evolution of MVT from experimental origins to a comprehensive clinical practice. The progress in surgical techniques and immunosuppression has broadened the spectrum of patients who can benefit from intestinal transplant, including both IIT and MVT. The expansion of indications offers hope to patients with complex gastrointestinal disorders. The detection of donor-specific antibodies in graft assessment advances diagnostic accuracy, ultimately improving patient outcomes.
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Affiliation(s)
- Phillipe Abreu
- Department of Surgery, University of Miami, Jackson Memorial Hospital, Miami Transplant Institute, Florida, USA
| | - Joao Manzi
- Department of Surgery, University of Miami, Jackson Memorial Hospital, Miami Transplant Institute, Florida, USA
- University of Sao Paulo Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | - Rodrigo Vianna
- Department of Surgery, University of Miami, Jackson Memorial Hospital, Miami Transplant Institute, Florida, USA
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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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Graft Versus Host Disease After Intestinal Transplantation: A Single-center Experience. Transplant Direct 2021; 7:e731. [PMID: 34291153 PMCID: PMC8291352 DOI: 10.1097/txd.0000000000001187] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 04/13/2021] [Indexed: 12/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. Background. Graft versus host disease (GVHD) is an uncommon but highly morbid complication of intestinal transplantation (ITx). In this study, we reviewed our 17-y experience with GVHD focusing on factors predicting GVHD occurrence and survival. Methods. Retrospective review of 271 patients who received 1 or more ITx since program inception in 2003 with survival analysis using Cox proportional hazard modeling. Results. Of 271 patients, 28 developed GHVD 34 (18–66) d after ITx presenting with rash or rash with fever in 26, rectosigmoid disease in 1, and hemolysis in 1; other sites, mainly rectosigmoid colon, were involved in 13. Initial skin biopsy demonstrated classic findings in 6, compatible findings in 14, and no abnormalities in 2. Additional sites of GVHD later emerged in 14. Of the 28 patients, 16 died largely from sepsis, the only independent hazard for death (hazard ratio [HR], 37.4181; P = 0.0008). Significant (P < 0.0500) independent hazards for occurrence of GVHD in adults were pre-ITx functional intestinal failure (IF) (HR, 15.2448) and non-IF diagnosis (HR, 20.9952) and early post-ITx sirolimus therapy (HR, 0.0956); independent hazards in children were non-IF diagnosis (HR, 4.3990), retransplantation (HR, 4.6401), donor:recipient age ratio (HR, 7.3190), and graft colon omission (HR, 0.1886). Variant transplant operation was not an independent GVHD hazard. Conclusions. Initial diagnosis of GVHD after ITx remains largely clinical, supported but not often confirmed by skin biopsy. Although GVHD risk is mainly recipient-driven, changes in donor selection and immunosuppression practice may reduce incidence and improve survival.
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Zhao XF, Lin DD, Li N, Wu JS, Guo QL, Wang L. Diagnosis and treatment of acute graft-versus-host disease after liver transplantation: A report of 11cases. Transpl Immunol 2020; 62:101307. [DOI: 10.1016/j.trim.2020.101307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 05/10/2020] [Accepted: 05/11/2020] [Indexed: 12/19/2022]
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Vela M, Stringa P, González-Navarro P, Machuca M, Pascual-Miguel B, Mestre C, Arreola NM, Papa-Gobbi R, Navarro-Zapata A, Pires-Lobo SC, Andrés AM, Hernández-Oliveros F, Pérez-Martínez A. Donor's graft ex vivo T-cell depletion with fludarabine reduces graft-versus-host disease signs and improves survival after intestinal transplantation - an experimental study. Transpl Int 2020; 33:1302-1311. [PMID: 32526809 DOI: 10.1111/tri.13672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 03/31/2020] [Accepted: 06/05/2020] [Indexed: 11/26/2022]
Abstract
Intestinal passenger T leukocytes are responsible for graft-versus-host disease (GvHD) in intestinal transplantation (ITx). We hypothesized that ex vivo fludarabine treatment of the bowel graft would diminish the risk of GvHD and improve overall survival post-transplant. We performed isolated heterotopic small bowel transplantations from Lewis (LEW) to Brown Norway (BN) rat strains, which generated GvHD signs from the fourth day post-transplant. These symptoms included rash, weight loss, piloerection, and diarrhea. The grafts of one of the experimental groups were immersed and sealed in cold Celsior preservation solution with 1000 µm fludarabine for 1 h, prior to its implantation into recipient animals. No histological signs of intestinal tissue alterations were observed after fludarabine treatment. Fludarabine-treated bowel recipients showed significantly later and milder clinical signs of GvHD and reduced total donor cell chimerism, as determined by flow cytometry using strain-specific anti-HLA antibodies. Additionally, fludarabine treatment prolonged recipients' overall survival (13.5 days ± 0.3 days vs. 9.2 days ± 0.5). We conclude that active modification of the intestinal leukocyte composition is advantageous in our ITx animal model. Immunosuppression with fludarabine during the surgical procedure, which could be translated directly to the clinic, protects bowel recipients from GvHD and improves overall post-transplant survival.
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Affiliation(s)
- Maria Vela
- Translational Research in Paediatric Oncology, Hematopoietic Transplantation & Cell Therapy, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Pablo Stringa
- Institute for Immunological and Physiopathological Studies (IIFP-CONICET-UNLP), National University of La Plata, Buenos Aires, Argentine
| | - Pablo González-Navarro
- Translational Research in Paediatric Oncology, Hematopoietic Transplantation & Cell Therapy, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Mariana Machuca
- Veterinary Pathology Laboratory, Veterinary Sciences Department, National University of La Plata, Buenos Aires, Argentine
| | - Bárbara Pascual-Miguel
- Translational Research in Paediatric Oncology, Hematopoietic Transplantation & Cell Therapy, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Carmen Mestre
- Translational Research in Paediatric Oncology, Hematopoietic Transplantation & Cell Therapy, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Nidia M Arreola
- Transplant Group - Experimental Surgery, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Rodrigo Papa-Gobbi
- Transplant Group - Experimental Surgery, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Alfonso Navarro-Zapata
- Translational Research in Paediatric Oncology, Hematopoietic Transplantation & Cell Therapy, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Sara C Pires-Lobo
- Transplant Group - Experimental Surgery, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain.,Paediatric Surgery Department, La Paz University Hospital, Madrid, Spain
| | - Ane M Andrés
- Transplant Group - Experimental Surgery, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain.,Paediatric Surgery Department, La Paz University Hospital, Madrid, Spain
| | - Francisco Hernández-Oliveros
- Transplant Group - Experimental Surgery, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain.,Paediatric Surgery Department, La Paz University Hospital, Madrid, Spain
| | - Antonio Pérez-Martínez
- Translational Research in Paediatric Oncology, Hematopoietic Transplantation & Cell Therapy, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain.,Paediatric Hemato-Oncology Department, La Paz University Hospital, Madrid, Spain
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Association of Alemtuzumab Induction With a Significantly Lower Incidence of GVHD Following Intestinal Transplantation: Results of 445 Consecutive Cases From a Single Center. Transplantation 2020; 104:2179-2188. [DOI: 10.1097/tp.0000000000003111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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7
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Current status of graft-versus-host disease after intestinal transplantation. Curr Opin Organ Transplant 2019; 24:199-206. [DOI: 10.1097/mot.0000000000000624] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Clouse JW, Kubal CA, Fridell JA, Pearsall EJ, Mangus RS. Post-intestine transplant graft-vs-host disease associated with inclusion of a liver graft and with a high mortality risk. Clin Transplant 2018; 33:e13409. [PMID: 30222903 DOI: 10.1111/ctr.13409] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 04/19/2018] [Accepted: 09/10/2018] [Indexed: 12/20/2022]
Abstract
INTRODUCTION This study reports the incidence, anatomic location, and outcomes of graft-vs-host disease (GVHD) at a single active intestine transplant center. METHODS Records were reviewed for all patients receiving an intestine transplant from 2003 to 2015. Pathology reports and pharmacy records were reviewed to establish the diagnosis, location, and therapeutic interventions for GVHD. RESULTS A total of 236 intestine transplants were performed during the study period, with 37 patients (16%) developing GVHD. The median time to onset of disease was 83 days, with 89% of affected patients diagnosed in the first year post-transplant. Mortality for affected patients was 54% in the 1 year after GVHD diagnosis. Skin lesions were the most common manifestation of GVHD. Other sites of disease included lungs, bone marrow, oral mucosa, large intestine, and brain. The incidence of GVHD was 16% in adult patients, and slightly lower in pediatric recipients (13%). In adults, increasing graft volume (isolated vs multi-organ) and liver inclusion were associated with increasing risk of GVHD, though this was not seen in pediatric patients. CONCLUSION Overall, 16% of intestine transplant recipients developed GVHD. GVHD is associated with high mortality, and disease in the lungs, brain, and bone marrow was universally fatal.
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Affiliation(s)
- Jared W Clouse
- Department of Surgery, Transplant Division, Indiana University School of Medicine, Indianapolis, Indiana
| | - Chandrashekhar A Kubal
- Department of Surgery, Transplant Division, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jonathan A Fridell
- Department of Surgery, Transplant Division, Indiana University School of Medicine, Indianapolis, Indiana
| | - E Jordan Pearsall
- Department of Surgery, Transplant Division, Indiana University School of Medicine, Indianapolis, Indiana
| | - Richard S Mangus
- Department of Surgery, Transplant Division, Indiana University School of Medicine, Indianapolis, Indiana
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Rambhia PH, Hanna R, Bergfeld WF. Graft versus host disease in a pediatric multiple organ transplant recipient with trichohepatoenteric syndrome - a unique case report. Int J Dermatol 2017; 57:89-91. [PMID: 29130476 DOI: 10.1111/ijd.13820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 09/28/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Pooja H Rambhia
- Department of Dermatology, Cleveland Clinic, Cleveland, OH, USA
| | - Rabbi Hanna
- Department of Pediatric Hematology Oncology and Blood and Bone Marrow Transplantation, Cleveland Clinic, Cleveland, OH, USA
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Severe Skin Complications After Small Bowel Transplantation: Graft-Versus-Host Disease, DRESS, Virus, or Drug Toxicity? Transplantation 2017; 100:2222-5. [PMID: 26950725 DOI: 10.1097/tp.0000000000001131] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Severe skin problems are uncommon after small bowel transplantation. Differential diagnosis includes drug reactions, infections, graft-versus-host disease (GVHD), and mixed diseases. Early diagnosis and treatment are determinant for prognosis. METHODS AND RESULTS We describe 6 patients with severe cutaneous complications after small bowel transplantation, the work-up, final diagnosis, and evolution. Two patients died from chronic GVHD or unrecognized drug rash with eosinophilia and systemic symptoms, the others recovered completely. In 2 patients, drugs and viruses could be implicated, and in 1 patient may have hidden or triggered chronic GVHD. Viruses (human herpesvirus 6, Epstein-Barr virus, and cytomegalovirus) were suspected to trigger drug rash with eosinophilia and systemic symptoms or GVHD. The 2 cases of acute GVHD were reversed completely by increased immunosuppression and anti-interleukin-2 receptor antibody. DISCUSSION In these severe cases, diagnosis is urgent and should include a careful evaluation of drug history, clinical presentation, biological investigations, infections, and toxic screening. A skin biopsy and chimerism study should be performed whenever possible. An early treatment is key to a positive outcome.
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Chang HK, Kim SY, Kim JI, Kim SI, Whang JK, Choi JY, Park JM, Jung ES, Rha SE, Kim DG, Moon IS, Lee MD. Ten-Year Experience With Bowel Transplantation at Seoul St. Mary's Hospital. Transplant Proc 2017; 48:473-8. [PMID: 27109981 DOI: 10.1016/j.transproceed.2015.12.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 12/29/2015] [Indexed: 12/12/2022]
Abstract
A retrospective review of intestinal transplantation (ITx) at Seoul St. Mary's Hospital was made by collecting clinical data over the past 10 years. Fifteen consecutive cases from 2004 were analyzed. Five children and 10 adults (6 months to 69 years of age) were included. Primary diseases in adults included 4 mesenteric vessel thromboses, 2 strangulations, and 1 each of visceral myopathy, malignant gastrointestinal stromal tumor (GIST), mesenteric lymphangiectasis, and injury. Pediatric cases involved 2 Hirschsprung disease, 2 visceral myopathy, and 1 necrotizing enterocolitis. Three of 7 stomas were closed using a serial transverse enteroplasty procedure before transplantation. The ITx were performed using 3 living-donor Itx, 12 deceased-donor ITx, 14 isolated Itx, and 1 modified multivisceral transplantation. Daclizumab, basiliximab, alemtusumab, or basiliximab with rabbit antithymocyte globulin (rATG) was used for the induction; tacrolimus monotherapy was used as the basic maintenance immunosuppressant; and m-TOR inhibitor was used for renal dysfunction patients. Seven cases of acute cellular rejection were treated with rATG. Three cases of antibody-mediated rejection were treated with rituximab alone or with rituximab and bortezomib combination. There were 4 cases of early mortality within 6 months after Itx. Causes of death were declamping shock, cardiac tamponade with acute cellular rejection, dysmotility, and sepsis. Surgical complications consisted of 1 feeding jejunostomy displacement, and a minor leakage at a colo-colostomy site. One-year survival of the patient and graft was 73.33% (Kaplan-Meier survival curve). Although the total number of ITx is small, its social impact has been remarkable in changing the related laws and reimbursement policy in Korea.
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Affiliation(s)
- H K Chang
- Department of Surgery, Intestinal Transplantation and Rehabilitation Unit, Organ Transplantation Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - S Y Kim
- Department of Surgery, Intestinal Transplantation and Rehabilitation Unit, Organ Transplantation Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - J I Kim
- Department of Surgery, Intestinal Transplantation and Rehabilitation Unit, Organ Transplantation Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - S I Kim
- Department of Internal Medicine, Intestinal Transplantation and Rehabilitation Unit, Organ Transplantation Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - J K Whang
- Department of Surgery, Daejeon St. Mary's Hospital, Daejeon, The Catholic University of Korea, Seoul, Korea
| | - J Y Choi
- Department of Internal Medicine, Intestinal Transplantation and Rehabilitation Unit, Organ Transplantation Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - J M Park
- Department of Internal Medicine, Intestinal Transplantation and Rehabilitation Unit, Organ Transplantation Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - E S Jung
- Department of Pathology, Intestinal Transplantation and Rehabilitation Unit, Organ Transplantation Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - S E Rha
- Department of Radiology, Intestinal Transplantation and Rehabilitation Unit, Organ Transplantation Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - D G Kim
- Department of Surgery, Intestinal Transplantation and Rehabilitation Unit, Organ Transplantation Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - I S Moon
- Department of Surgery, Intestinal Transplantation and Rehabilitation Unit, Organ Transplantation Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - M D Lee
- Department of Surgery, Intestinal Transplantation and Rehabilitation Unit, Organ Transplantation Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea.
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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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