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Alyamany R, Alnughmush A, Albaiz F, Aversa M, Law A. Treatment of Late-onset Acute Graft-versus-host Disease Following Double Lung Transplantation Using a JAK2 Inhibitor. Transplantation 2024:00007890-990000000-00892. [PMID: 39375898 DOI: 10.1097/tp.0000000000005226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/09/2024]
Abstract
Acute graft-versus-host disease (aGVHD) is a rare but potentially life-threatening complication that can occur after solid organ transplantation, particularly in organs with abundant lymphoid tissue like the liver and intestines. While less common in lung transplants, the rising numbers of these procedures have brought more attention to aGVHD, usually appearing within the first 3-mo posttransplant. Given its relative rarity, a clear understanding of the pathophysiology, risk factors, diagnostic, and management strategies remain elusive. These knowledge gaps can lead to delays in diagnosis and the initiation of appropriate treatment leading to predictably inferior outcomes. Managing aGVHD following solid organ transplantation is challenging, and there is no standard approach. Current management involves high-dose steroids and other immunosuppressive drugs. However, these interventions are associated with serious complications, including potentially fatal infections, underscoring the urgent need for more research to refine both diagnostic methods and treatment approaches and ultimately improving patient outcomes. In this report, we aim to deepen our understanding of aGVHD following lung transplants and share our experience with a unique case of aGVHD occurring almost a year after lung transplantation that was successfully managed using ruxolitinib, describing a potential treatment approach modeled on the contemporary management of stem cell transplant associated aGVHD.
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Affiliation(s)
- Ruah Alyamany
- Hans Messner Allogeneic Blood and Marrow Transplant Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Department of Hematology, Stem Cell Transplant and Cellular Therapy, Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ahmed Alnughmush
- Hans Messner Allogeneic Blood and Marrow Transplant Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Department of Hematology, Stem Cell Transplant and Cellular Therapy, Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Faisal Albaiz
- Division of Respirology, Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
- Lung Heath Centre, Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Meghan Aversa
- Division of Respirology, Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Arjun Law
- Hans Messner Allogeneic Blood and Marrow Transplant Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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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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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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Galderisi U, Peluso G, Di Bernardo G. Clinical Trials Based on Mesenchymal Stromal Cells are Exponentially Increasing: Where are We in Recent Years? Stem Cell Rev Rep 2021; 18:23-36. [PMID: 34398443 PMCID: PMC8365566 DOI: 10.1007/s12015-021-10231-w] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2021] [Indexed: 12/16/2022]
Abstract
Mesenchymal stromal cells (MSCs), present in the stromal component of several tissues, include multipotent stem cells, progenitors, and differentiated cells. MSCs have quickly attracted considerable attention in the clinical field for their regenerative properties and their ability to promote tissue homeostasis following injury. In recent years, MSCs mainly isolated from bone marrow, adipose tissue, and umbilical cord—have been utilized in hundreds of clinical trials for the treatment of various diseases. However, in addition to some successes, MSC-based therapies have experienced several failures. The number of new trials with MSCs is exponentially growing; still, complete results are only available for a limited number of trials. This dearth does not help prevent potentially inefficacious and unnecessary clinical trials. Results from unsuccessful studies may be useful in planning new therapeutic approaches to improve clinical outcomes. In order to bolster critical analysis of trial results, we reviewed the state of art of MSC clinical trials that have been published in the last six years. Most of the 416 published trials evaluated MSCs’ effectiveness in treating cardiovascular diseases, GvHD, and brain and neurological disorders, although some trials sought to treat immune system diseases and wounds and to restore tissue. We also report some unorthodox clinical trials that include unusual studies.
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Affiliation(s)
- Umberto Galderisi
- Department of Experimental Medicine, Luigi Vanvitelli Campania University, Naples, Italy.,Center for Biotechnology, Sbarro Institute for Cancer Research and Molecular Medicine, Temple University, Philadelphia, PA, USA.,Genome and Stem Cell Center (GENKÖK), Erciyes University, Kayseri, Turkey
| | | | - Giovanni Di Bernardo
- Department of Experimental Medicine, Luigi Vanvitelli Campania University, Naples, Italy. .,Center for Biotechnology, Sbarro Institute for Cancer Research and Molecular Medicine, Temple University, Philadelphia, PA, USA.
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Russell AJ, Musiek AC, Staser KW, Rosman IS. Histopathologic and immunophenotypic features of cutaneous solid organ transplant-associated graft-vs-host disease: Comparison with acute hematopoietic cell transplant-associated graft-vs-host disease and cutaneous drug eruption. J Cutan Pathol 2021; 48:1480-1488. [PMID: 34173980 DOI: 10.1111/cup.14093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/21/2021] [Accepted: 06/23/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although it is relatively common after hematopoietic cell transplant (HCT), graft-vs-host disease (GVHD) is a rare complication following solid organ transplantation (SOT). METHODS This study evaluated skin biopsy specimens from five cases of SOT GVHD, 15 cases of HCT GVHD, and 15 cases of cutaneous drug eruption. Immunohistochemical staining for CD3, CD4, CD8, T-bet, and GATA-3 was performed to examine the density and immune phenotype of skin-infiltrating lymphocytes. RESULTS Similar to HCT GVHD, the predominant histopathologic findings in skin biopsy specimens of SOT GVHD were widespread vacuolar interface dermatitis with scattered necrotic keratinocytes. However, the density of dermal inflammation was considerably higher in SOT GVHD. Features that were more predictive of a cutaneous drug eruption over GVHD included spongiosis, confluent parakeratosis, and many eosinophils. Involvement of the hair follicle epithelium was seen in all three disorders. Both forms of cutaneous GVHD showed a predominance of Th1 (CD3+/T-bet+) lymphocytes within the inflammatory infiltrates. This shift was more pronounced in SOT GVHD, particularly among intraepidermal T-cells. CONCLUSIONS SOT GVHD shares many histopathologic features with HCT GVHD. However, SOT GVHD has a greater tendency to develop brisk lichenoid inflammation.
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Affiliation(s)
- Aaron J Russell
- Department of Medicine, Division of Dermatology, Washington University School of Medicine, St. Louis, Missouri, USA.,Departments of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Amy C Musiek
- Department of Medicine, Division of Dermatology, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - Ilana S Rosman
- Department of Medicine, Division of Dermatology, Washington University School of Medicine, St. Louis, Missouri, USA.,Departments of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA
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Chan SL, Wood BA, Mesbah Ardakani N. Eczematous graft-vs-host disease: A report of three cases and review of the literature. J Cutan Pathol 2020; 47:1085-1095. [PMID: 32767402 DOI: 10.1111/cup.13836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 07/03/2020] [Accepted: 07/29/2020] [Indexed: 11/30/2022]
Abstract
Graft-vs-host disease (GVHD) is the most common complication following hematopoietic cell transplantation, which affects skin frequently. Acute and chronic forms of GVHD manifest commonly as maculopapular to morbilliform eruptions and sclerotic or lichen-planus-like lesions, respectively; however, atypical presentations such as eczema-like GVHD may occur at times. We describe three cases of GVHD with diverse and polymorphous cutaneous eruptions including pompholyx-like and vasculitis-like rash as well as erythematous plaques and papulosquamous eruptions, with skin biopsy showing unifying histopathological findings with concurrent changes of spongiotic dermatitis and vacuolar interface reaction with apoptotic keratinocytes. In addition, the clinical and pathological features of previously reported cases of eczema-like GVHD are reviewed. It is emphasized that the course of the disease can be variable and successful management often involves a combination of multiple therapeutic modalities including immunosuppression with or without ultraviolet therapy. These cases highlight the importance of meticulous clinicopathological correlation with careful exclusion of mimicking conditions to arrive at the correct diagnosis.
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Affiliation(s)
- Su-Lin Chan
- Department of Dermatology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Benjamin Andrew Wood
- Department of Anatomical Pathology, PathWest Laboratory Medicine, QEII Medical Centre, Perth, Western Australia, Australia.,School of Pathology and Laboratory Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Nima Mesbah Ardakani
- Department of Anatomical Pathology, PathWest Laboratory Medicine, QEII Medical Centre, Perth, Western Australia, Australia.,School of Pathology and Laboratory Medicine, The University of Western Australia, Perth, Western Australia, Australia.,College of Science, Health, Engineering and Education, Murdoch University, Perth, Western Australia, Australia
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Malone AF, Wu H, Fronick C, Fulton R, Gaut JP, Humphreys BD. Harnessing Expressed Single Nucleotide Variation and Single Cell RNA Sequencing To Define Immune Cell Chimerism in the Rejecting Kidney Transplant. J Am Soc Nephrol 2020; 31:1977-1986. [PMID: 32669324 DOI: 10.1681/asn.2020030326] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/10/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND In solid organ transplantation, donor-derived immune cells are assumed to decline with time after surgery. Whether donor leukocytes persist within kidney transplants or play any role in rejection is unknown, however, in part because of limited techniques for distinguishing recipient from donor cells. METHODS Whole-exome sequencing of donor and recipient DNA and single-cell RNA sequencing (scRNA-seq) of five human kidney transplant biopsy cores distinguished immune cell contributions from both participants. DNA-sequence comparisons used single nucleotide variants (SNVs) identified in the exome sequences across all samples. RESULTS Analysis of expressed SNVs in the scRNA-seq data set distinguished recipient versus donor origin for all 81,139 cells examined. The leukocyte donor/recipient ratio varied with rejection status for macrophages and with time post-transplant for lymphocytes. Recipient macrophages displayed inflammatory activation whereas donor macrophages demonstrated antigen presentation and complement signaling. Recipient-origin T cells expressed cytotoxic and proinflammatory genes consistent with an effector cell phenotype, whereas donor-origin T cells appeared quiescent, expressing oxidative phosphorylation genes. Finally, both donor and recipient T cell clones within the rejecting kidney suggested lymphoid aggregation. The results indicate that donor-origin macrophages and T cells have distinct transcriptional profiles compared with their recipient counterparts, and that donor macrophages can persist for years post-transplantation. CONCLUSIONS Analysis of single nucleotide variants and their expression in single cells provides a powerful novel approach to accurately define leukocyte chimerism in a complex organ such as a transplanted kidney, coupled with the ability to examine transcriptional profiles at single-cell resolution.
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Affiliation(s)
- Andrew F Malone
- Division of Nephrology, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Haojia Wu
- Division of Nephrology, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Catrina Fronick
- McDonnell Genome Institute, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Robert Fulton
- McDonnell Genome Institute, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Joseph P Gaut
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Benjamin D Humphreys
- Division of Nephrology, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri .,Department of Developmental Biology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
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Jacobs MT, Olson M, Ferreira BP, Jin R, Hachem R, Byers D, Witt C, Ghobadi A, DiPersio JF, Pusic I. The use of ruxolitinib for acute graft-versus-host disease developing after solid organ transplantation. Am J Transplant 2020; 20:589-592. [PMID: 31446673 DOI: 10.1111/ajt.15579] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/23/2019] [Accepted: 08/09/2019] [Indexed: 01/25/2023]
Abstract
Development of graft-versus-host disease (GvHD) is a rare complication after transfusions or solid organ transplantation. Patients typically present with a skin rash, diarrhea, liver failure, and bone marrow aplasia. A diagnosis of transfusion/transplantation associated-GvHD is made based on the clinical and histologic evidence, yet it is often delayed due to the nonspecific symptoms attributed to the patient's underlying illness. Several therapeutic approaches are being used including both increasing and withdrawing immunosuppression, and the use of cellular therapies. Unfortunately, the success rate of these approaches is low and the mortality of this complication is very high. New approaches are needed. We report on three cases of GvHD developing after solid organ transplantation treated with ruxolitinib.
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Affiliation(s)
- Miriam T Jacobs
- Division of Oncology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Marissa Olson
- Division of Oncology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Bruna Pellini Ferreira
- Division of Oncology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Ramon Jin
- Division of Oncology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Ramsey Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Derek Byers
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Chad Witt
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Armin Ghobadi
- Division of Oncology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - John F DiPersio
- Division of Oncology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Iskra Pusic
- Division of Oncology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
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Abstract
Graft-versus-host disease (GVHD) is a common complication of hematopoietic stem cell transplantation but can rarely occur after solid organ transplants. Small bowel and liver transplants are typically implicated, but solid organ transplant-associated GVHD has also been associated with other organs. We present a 40-year-old diabetic woman who underwent renal followed by pancreatic transplantation over a span of 21 months and ultimately developed acute classic GVHD. The diagnosis proved to be challenging in the context of confounding infections and inconclusive bone marrow and skin biopsy findings. She had multiorgan failure at the time of endoscopic confirmation and died after having minimal response to aggressive immunosuppression.
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Auerbach JS, Schott CK. Solid-Organ Graft-Versus-Host Disease After Liver Transplant: A Case Report. Crit Care Nurse 2018; 36:e7-e11. [PMID: 27252108 DOI: 10.4037/ccn2016988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Solid-organ transplant graft-versus-host disease (SOT-GVHD) is a rare complication of organ transplant that is associated with high mortality. The initial signs and symptoms are vague, so this disease is easily confused with other posttransplant complications. A case of SOT-GVHD occurred after orthotopic liver transplant for liver failure due to hepatitis C in a patient in a Veterans Affairs intensive care unit. The patient had dehydration, acute kidney injuries, rashes, diarrhea, and pancytopenia. Results of skin biopsy, bone marrow biopsy, and cytogenetic studies were consistent with SOT-GVHD. Despite supportive care including antibiotics, antiviral and antifungal therapy, high-dose steroids, antithymoglobulin and neupogen, the patient died of overwhelming sepsis. Owing to the rarity of SOT-GVHD, no evidence-based guidelines or recommendations for treatment exist. Treatment includes high-dose corticosteroids and antibiotic, antifungal, and antiviral prophylaxis. Treatment of liver transplant-related GVHD with anti-tumor necrosis factor a agents has been successful.
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Affiliation(s)
- Jonathan S Auerbach
- Jonathan S. Auerbach is a critical care intensivist at Boca Raton Regional and Bethesda Hospitals and is an affiliate assistant professor of clinical biomedical science in the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida.Christopher K. Schott is on staff at VA Pittsburgh Health Care Systems and is an assistant professor of critical care and emergency medicine, director of critical care ultrasonography, and director of the medical student critical care elective at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christopher K Schott
- Jonathan S. Auerbach is a critical care intensivist at Boca Raton Regional and Bethesda Hospitals and is an affiliate assistant professor of clinical biomedical science in the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida.Christopher K. Schott is on staff at VA Pittsburgh Health Care Systems and is an assistant professor of critical care and emergency medicine, director of critical care ultrasonography, and director of the medical student critical care elective at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Dermatologic manifestations of solid organ transplantation-associated graft-versus-host disease: A systematic review. J Am Acad Dermatol 2017; 78:1097-1101.e1. [PMID: 29288097 DOI: 10.1016/j.jaad.2017.12.050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 12/12/2017] [Accepted: 12/18/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Graft-versus-host-disease (GVHD) after solid organ transplantation (SOT) is extremely rare. OBJECTIVE To investigate the dermatologic manifestations and clinical outcomes of SOT GVHD. METHODS Systematic literature review of SOT GVHD. RESULTS After full-text article review, we included 61 articles, representing 115 patients and 126 transplanted organs. The most commonly transplanted organ was the liver (n = 81). Among 115 patients, 101 (87.8%) developed skin involvement. The eruption appeared an average of 48.3 days (range, 3-243 days) posttransplant and was pruritic in 5 of 101 (4.9%) cases. The eruption was described as morbilliform in 2 patients (1.9%), confluent in 6 (5.9%), and desquamative in 4 (3.9%) cases. In many cases, specific dermatologic descriptions were lacking. The mortality rate was 72.2%. Relative time of death was reported in 23 patients who died during the follow-up period. These patients died an average of 99.2 days (range, 22-270 days) posttransplant, or 50.9 days after the appearance of dermatologic symptoms. Frequent causes of death were sepsis and multiorgan failure. LIMITATIONS Incomplete descriptions of skin findings and potential publication bias resulting in publication of only the most severe cases. CONCLUSIONS GVHD is a potentially fatal condition that can occur after SOT and often presents with a skin rash. We recommend that dermatologists have a low threshold to consider and pursue this diagnosis in the setting of post-SOT skin eruption.
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Rashidi A, Brennan DC, Amarillo IE, Wellen JR, Cashen A. Mixed Donor Chimerism Following Simultaneous Pancreas-Kidney Transplant. EXP CLIN TRANSPLANT 2017; 16:307-313. [PMID: 28661312 DOI: 10.6002/ect.2016.0299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Graft-versus-host disease after solid-organ transplant is exceedingly rare. Although the precise pathogenetic mechanisms are unknown, a progressive increase in donor chimerism is a requirement for its development. The incidence of mixed donor chimerism and its timeline after simultaneous pancreas-kidney transplant is unknown. MATERIALS AND METHODS After encountering 2 cases of graft-versus-host disease after simultaneous pancreas-kidney transplant at our institution over a period of < 2 years, a collaborative pilot study was conducted by the bone marrow transplant, nephrology, and abdominal transplant surgery teams. We enrolled all consecutive patients undergoing sex-mismatched simultaneous pancreas-kidney transplant over 1 year and longitudinally monitored donor chimerism using fluorescence in situ hybridization for sex chromosomes. RESULTS We found no evidence for chimerism in our 7 patients. In a comprehensive literature review, we found a total of 25 previously reported cases of graft-versus-host disease after kidney, pancreas, and simultaneous pancreas-kidney transplants. The median onset of graft-versus-host disease was approximately 5 weeks after transplant, with a median of about 2 weeks of delay between first presentation and diagnosis. Skin, gut, and bone marrow were almost equally affected at initial presentation, and fever of unknown origin occurred in more than half of patients. The median survival measured from the first manifestation of graft-versus-host disease was only 48 days. CONCLUSIONS Within the limitations related to small sample size, our results argue against an unusually high risk of graft-versus-host disease after simultaneous pancreas-kidney transplant. Collaboration between solid-organ and stem cell transplant investigators can be fruitful and can improve our understanding of the complications that are shared between the 2 fields.
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Affiliation(s)
- Armin Rashidi
- U.O.C. Division of Immunohematology, Transfusion Medicine and Transplant Immunology, Regional Reference Laboratory of Transplant Immunology, Azienda Ospedaliera Universitaria, Second University of Naples, Naples, Italy
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Graft Versus Host Disease After Liver Transplantation in Adults: A Case series, Review of Literature, and an Approach to Management. Transplantation 2017; 100:2661-2670. [PMID: 27495762 DOI: 10.1097/tp.0000000000001406] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Graft-versus-host-disease (GVHD) after liver transplantation (LT) is a deadly complication with very limited data on risk factors, diagnosis and management. We report a case series and a comprehensive review of the literature. METHODS Data were systematically extracted from reports of GVHD after LT, and from the United Network for Organ Sharing database. Group comparisons were performed. RESULTS One hundred fifty-six adult patients with GVHD after LT have been reported. Median time to GVHD onset was 28 days. Clinical features were skin rash (92%), pancytopenia (78%), and diarrhea (65%). Six-month mortality with GVHD after LT was 73%. Sepsis was the most common cause of death (60%). Enterobacter bacteremia, invasive aspergillosis, and disseminated Candida infections were frequently reported. Recipient age over 50 years is a risk factor for GVHD after LT. Hepatocellular carcinoma was overrepresented, whereas chronic hepatitis C was underrepresented, in reported United States GVHD cases relative to all United Network for Organ Sharing database LT cases. Mortality rate with treatment of GVHD after LT was 84% with high-dose steroids alone, 75% to 100% with regimens using dose increases of calcineurin inhibitors, and 55% with IL-2 antagonists. Mortality was 25% in small case series using the CD2-blocker alefacept or TNF-α antagonists. CONCLUSIONS Age older than 50 years and hepatocellular carcinoma appear to be risk factors for GVHD. Hepatitis C may be protective. High-dose steroids and calcineurin inhibitors are ineffective in the treatment of GVHD after LT. CD2-blockers and TNF-α antagonists appear promising. We propose a diagnostic algorithm to assist clinicians in managing adults with GVHD after LT.
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Guo Y, Ding S, Guo H, Li S, Lu X, Chen Z, Chen ZK, Ming C, Gong N. Graft-versus-host-disease after kidney transplantation: A case report and literature review. Medicine (Baltimore) 2017; 96:e7333. [PMID: 28658148 PMCID: PMC5500070 DOI: 10.1097/md.0000000000007333] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Acute graft-versus-host-disease (GVHD) in kidney recipients is extremely rare. Knowledge about its clinical manifestations, diagnosis, treatment, and prognosis is limited and needs to be increased. CLINICAL FINDINGS One male kidney transplant recipient developed diarrhea and suffered kidney function damage. Primarily diagnosed with acute rejection, he was given methylprednisolone (MP) bolus treatment. Meanwhile, intravenous immunoglobulin (IVIG) and decreased immunosuppressive agents were applied for the corresponding infection. During the treatment, skin rashes occurred over his whole body. Biopsies were then taken. The pathology of the kidney graft showed no rejection, while the skin pathology revealed typical GVHD. Furthermore, fluorescence in situ hybridization proved the presence of donor-derived cells in the skin lesions, and infiltrating cytotoxic T cells and NK cells were identified in the rash. OUTCOME Based on the clinical presentations, pathological findings, and chimerism detection, GVHD after kidney transplantation was confirmed as the final diagnosis. The recipient responded well to treatment. His kidney function recovered, and the skin lesions were completely resolved. He has been followed for 1 year without any further episodes. CONCLUSION GVHD after kidney transplantation has its own characteristics. In the presence of a highly immunocompromised state, diarrhea and rashes, a diagnosis of GVHD needs to be considered. Kidney function impairment may be involved. Pathological changes and detection of chimerism and immunocyte infiltration are required for diagnosis. MP bolus, IVIG, and decreased immunosuppression could be beneficial to the clinical outcome. Kidney recipients have a prognosis superior to recipients of organs bearing large numbers of lymphocytes.
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Affiliation(s)
- Yanhua Guo
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Shouyang Ding
- Department of Transplantation, Central Hospital of Yiyang, Yiyang
| | - Hui Guo
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Shenqiu Li
- Department of Dermatology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xia Lu
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Zhishui Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Zhonghua Klaus Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Changsheng Ming
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Nianqiao Gong
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
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West FB, Kelher MR, Silliman CC. Red Blood Cell Transfusion. TRAUMA INDUCED COAGULOPATHY 2016. [PMCID: PMC7178873 DOI: 10.1007/978-3-319-28308-1_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Blood is classified as a drug and transfusion is one of the most commonly performed procedures in the USA. General knowledge of blood manufacturing, shelf life and storage media, common component modifications, blood types, and product compatibility allows the clinician to better communicate their needs and to understand what options may be available when ordering blood products. All transfusions offer benefits, and the clinician must comprehend the possible adverse events, especially those related to TRALI, which continues to be the most common cause of transfusion-related death reported to FDA, with TACO as the second most-commonly reported event. Transfusing in the setting of hemorrhagic blood loss adds additional challenges regarding volume overload, coagulopathy, and optimum transfusion ratios of red cells, plasma, platelets, and cryoprecipitate. The information imparted in this chapter will help equip the clinician with the knowledge needed to make the best decisions for patients requiring blood products, especially injured patients.
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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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Rossi AP, Bone BA, Edwards AR, Parker MK, Delos Santos RB, Hagopian J, Lockwood C, Musiek A, Klein CL, Brennan DC. Graft-versus-host disease after simultaneous pancreas-kidney transplantation: a case report and review of the literature. Am J Transplant 2014; 14:2651-6. [PMID: 25219902 DOI: 10.1111/ajt.12862] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 06/02/2014] [Accepted: 06/03/2014] [Indexed: 01/25/2023]
Abstract
Graft-versus-host disease (GVHD) after solid organ transplantation is rare and usually fatal. We present, to our knowledge, the second successfully treated case in a simultaneous pancreas-kidney (SPK) transplant recipient. A 29-year-old female with end-stage renal disease from type 1 diabetes mellitus received an SPK transplant from a male donor, with rabbit-antithymocyte globulin induction. Twelve days posttransplant, she was readmitted with abdominal pain, nausea and vomiting. She developed leukopenia, abnormal liver enzymes, fever and a skin rash. Skin biopsy showed interface dermatitis consistent with allergic reaction versus GVHD. Fluorescence in situ hybridization of the skin biopsy showed 28% of cells had a Y chromosome confirming GVHD. Short tandem repeats (STR) enriched for CD3+ cells from peripheral blood showed a mixed chimerism. She was successfully treated with a single plasmapheresis to remove antithymocyte globulin, high-dose steroids, photopheresis and high tacrolimus levels (12-15 ng/mL). Five months after transplantation, she has normal renal function and white blood cell count, normal hemoglobin A1C and no evidence of peripheral blood donor chimerism. In conclusion, early diagnosis of GVHD after SPK transplantation may allow successful treatment. STR enriched for CD3+ may be useful to evaluate the response to therapy.
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Affiliation(s)
- A P Rossi
- Transplant Nephrology, Washington University in St. Louis, St. Louis, MO
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19
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Guy S, Potluri A, Xiao G, Vega ML, Malat G, Ranganna K, Cusack C, Doyle AM. Successful treatment of acute severe graft-versus-host-disease in a pancreas-after-kidney transplant recipient: case report. Transplant Proc 2014; 46:2446-9. [PMID: 25179161 DOI: 10.1016/j.transproceed.2014.06.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 06/17/2014] [Indexed: 10/24/2022]
Abstract
The development of acute graft-versus-host-disease (GVHD) in recipients of pancreas transplants is a rare and quite often a fatal post-transplantation complication. We present a 38-year-old male with a longstanding history of type 1 diabetes mellitus and end-stage kidney disease, with a living unrelated kidney transplant from his wife for 3 years, who received an enteric-drained 5-antigen HLA-mismatched deceased-donor pancreas. Five weeks after transplantation, he presented with spiking fevers, severe skin rash, diarrhea, pancytopenia, and increasingly abnormal liver function tests. Skin biopsies were consistent with grade 3 acute GVHD. The patient was treated for GVHD with escalated doses of tacrolimus, pulse doses of steroids, and basiliximab. He was discharged after a 4-week hospital stay with complete resolution of his rash, fever, abnormal liver enzymes, and leukopenia. He remained in good health with excellent kidney and pancreas allograft function 3 years later.
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Affiliation(s)
- S Guy
- Division of Solid Organ Transplantation, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - A Potluri
- Division of Solid Organ Transplantation, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - G Xiao
- Division of Solid Organ Transplantation, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - M L Vega
- Division of Dermatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - G Malat
- Division of Solid Organ Transplantation, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - K Ranganna
- Division of Solid Organ Transplantation, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - C Cusack
- Division of Dermatology, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - A M Doyle
- Division of Solid Organ Transplantation, Drexel University College of Medicine, Philadelphia, Pennsylvania.
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20
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Chang JW, Sageshima J, Ciancio G, Mattiazzi A, Chen L, Tsai HL, Ruiz P, Burke GW. Successful treatment for graft-versus-host disease after pancreas transplantation. Clin Transplant 2014; 28:217-22. [PMID: 24433450 DOI: 10.1111/ctr.12300] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2013] [Indexed: 11/29/2022]
Abstract
Graft-versus-host disease (GVHD) after pancreas transplantation is a rare but serious complication: All previously reported cases were fatal. We herein report three cases of GVHD after pancreas transplantation with favorable outcomes. Patients with a history of kidney (and pancreas) transplantation subsequently received a pancreas (and kidney) transplantation (i.e., pancreas retransplantation or pancreas after kidney transplantation) and developed acute GVHD. All of them responded to increased immunosuppression (e.g., steroid bolus, antithymocyte globulin) and retained normal graft function. Because the clinical manifestations are non-specific, vigilance is necessary to make an accurate diagnosis. We underscored the importance of a biopsy of involved organs and the clinicopathologic correlation in the early diagnosis of GVHD. Augmented immunosuppression to prevent progression from a self-limited disease to life-threatening pancytopenia or sepsis may be most critical to improve outcome.
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Affiliation(s)
- Jei wen Chang
- Division of Kidney and Pancreas Transplantation, Dewitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Department of Pediatrics and Surgery, School of Medicine, Taipei Veterans General Hospital Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
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21
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Kanterman J, Sade-Feldman M, Baniyash M. New insights into chronic inflammation-induced immunosuppression. Semin Cancer Biol 2012; 22:307-18. [PMID: 22387003 DOI: 10.1016/j.semcancer.2012.02.008] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 02/15/2012] [Indexed: 01/11/2023]
Abstract
Chronic inflammation is a common factor linking various pathologies that differ in their etiology and physiology such as cancer, autoimmune diseases, and infections. At a certain stage of each of these diseases, while the chronic inflammation proceeds, some key players of the immune system become immunosuppressed as natural killer (NK) cells and T cells. The suppressive environment induced during chronic inflammation is governed by a complex processes characterized by the accumulation and activation of immune suppressor cells, pro-inflammatory cytokines, chemokines, growth and angiogenic factors, and by the activation of several inflammatory signaling pathways mediated predominantly by NFκB and STAT3 transcription factors. A substantial body of evidence supports the notion that the development of a suppressive environment during chronic inflammation limits the success of immune-based and conventional therapies, skewing the balance in favor of a developing pathology. Thus, appropriate, well-designed and fine tuned immune interventions that could resolve inflammatory responses and associated immunosuppression could enhance disease regression and reinforce successful responses to a given therapy. This review describes the interrelationship between chronic inflammation and induced immunosuppression, and explains the current evidence linking inflammation and pathological processes, as found in cancer. We further highlight potential strategies, harnessing the immunosuppressive environment in treating autoimmune diseases and facilitating transplantation. In parallel, we emphasize the use of modalities to combat chronic inflammation-induced immunosuppression in cancer, to enhance the success of immune-based therapies leading to tumor regression. In both cases, the urgent necessity of identifying biomarkers for the evaluation of host immune status is discussed, with the goal of developing optimal personalized treatments.
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Affiliation(s)
- Julia Kanterman
- The Lautenberg Center for General and Tumor Immunology, The Hebrew University-Hadassah Medical School, Jerusalem, Israel
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22
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Xu X, Ling Q, Wei Q, Wang K, Zhou B, Zhuang L, Zhou L, Zheng S. Korean red ginseng: a new approach for the treatment of graft-versus-host disease after liver transplantation. Transplant Proc 2012; 43:2651-5. [PMID: 21911140 DOI: 10.1016/j.transproceed.2011.06.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 05/16/2011] [Accepted: 06/03/2011] [Indexed: 02/05/2023]
Abstract
BACKGROUND Graft-versus-host disease (GVHD) is a rare complication after liver transplantation with an extremely poor prognosis; its occurrence offers great challenges. METHODS We have reported herein one case of acute GVHD after liver transplantation who was treated with a traditional Chinese medicine named Korean Red Ginseng (KRG). RESULTS The acute GVHD was successfully cured by KRG. CONCLUSIONS The successful salvage of acute GVHD after liver transplantation by KRG may provide a new viable therapeutic option.
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Affiliation(s)
- X Xu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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23
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Kim JM, Kim SJ, Joh JW, Kwon CHD, Jang KT, An J, Ki CS, Kang ES, Shin M, Kim BN, Lee SK. Graft-versus-host disease after kidney transplantation. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2011; 80 Suppl 1:S36-9. [PMID: 22066080 PMCID: PMC3205370 DOI: 10.4174/jkss.2011.80.suppl1.s36] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2010] [Accepted: 07/15/2010] [Indexed: 11/30/2022]
Abstract
Graft-versus-host disease (GVHD) is a rare complication after kidney transplantation. We describe a 62-year-old female with end-stage renal disease due to hypertension. She received a kidney with 4 mismatched human leukocyte antigen (HLA) out of 6 HLA - A, B, DR from a deceased donor. After the procedure, the patient showed watery diarrhea on postoperative day (POD) 45. An endoscopic biopsy of the colon revealed some apoptotic cells consistent with GVHD. Thrombocytopenia was gradually developed on POD 54. She received steroid pulse therapy, and thrombocytopenia did not progress. However, pneumonia, renal failure, and cardiac failure occurred. She died due to multiple organ failure. We must consider GVHD in renal transplant recipients without homozygous or identical HLA, who had only watery diarrhea without other typical GVHD symptoms such as skin rash and fever, although GVHD is rare in renal transplant recipients.
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Affiliation(s)
- Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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24
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Osband AJ, Laskow DA, Mann RA. Treatment of acute graft-vs-host disease after simultaneous pancreas-kidney transplantation: a case report. Transplant Proc 2011; 42:3894-7. [PMID: 21094880 DOI: 10.1016/j.transproceed.2010.08.058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Revised: 07/16/2010] [Accepted: 08/26/2010] [Indexed: 11/17/2022]
Abstract
Whereas neutropenia is common after solid-organ transplantation, graft-vs-host disease is unusual, especially after simultaneous pancreas-kidney transplantation. Most cases reported in the literature give few details of treatment approach, and all were fatal. A 45-year-old man with diabetes underwent simultaneous pancreas-kidney transplantation at our center, with organs from a female donor. Two weeks postoperatively, he was readmitted with fever, malaise, and neutropenia. A bone marrow biopsy specimen demonstrated that two-thirds of the lymphocytes were of female karyotype. Graft-vs-host disease was diagnosed. Aggressive immunosuppression therapy was administered; however, the patient died. To our knowledge, this is the first case report with specific details of a treatment protocol and sequential short tandem repeat data.
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Affiliation(s)
- A J Osband
- Kidney and Pancreas Transplant Center, Robert Wood Johnson Medical School, 10 Plum St, 7th Floor, New Brunswick, NJ 08901, USA.
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25
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Zhang Y, Ruiz P. Solid organ transplant-associated acute graft-versus-host disease. Arch Pathol Lab Med 2010; 134:1220-4. [PMID: 20670147 DOI: 10.5858/2008-0679-rs.1] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Solid organ transplant-associated graft-versus-host disease is an infrequent and potentially lethal complication. The incidence of this complication varies according to the type of organ transplant with higher rates associated with liver and small bowel transplants. The clinical presentation typically includes fever and skin rash, and most cases quickly advance to become a multisystem disease affecting the bone marrow and other nontransplanted solid organs. The diagnosis is based on the clinical symptoms, pathologic changes in biopsied tissues, and systemic lymphoid chimerism. The mortality of this disease can exceed 75% after liver transplant and most patients die from infections or hemorrhage due to bone marrow failure. There is no standard treatment strategy for this complication, and the management mainly consists of both prophylaxis and immediate treatment without delay. This short review summarizes the current pathogenesis, diagnosis, and treatment of this entity.
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Affiliation(s)
- Yaxia Zhang
- Department of Pathology, University of Miami-Jackson Memorial Hospital and Sylvester Comprehensive Cancer Center, Miami, Florida, USA
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26
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Kato T, Yazawa K, Madono K, Saito J, Hosomi M, Itoh K. Acute graft-versus-host-disease in kidney transplantation: case report and review of literature. Transplant Proc 2010; 41:3949-52. [PMID: 19917421 DOI: 10.1016/j.transproceed.2009.05.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Accepted: 05/04/2009] [Indexed: 11/17/2022]
Abstract
Graft-versus-host-disease (GVHD) is a complication of solid organ transplantation, most commonly of the small bowel or liver. Herein, we have presented a case of GVHD in a 27-year-old man who underwent an human leukocyte antigen (HLA) minor mismatch renal transplantation from his father. After the procedure, the patient presented with a fever, skin rash, and watery diarrhea. An allograft kidney biopsy demonstrated no sign of rejection; however, anti-A antibody was detected in plasma and progressive anemia was attributed to hemolytic anemia owing to a passenger lymphocyte syndrome. From those findings, we suspected that the clinical symptoms were caused by acute GVHD. An endoscopic biopsy of the colon revealed apoptotic cells consistent with the disease. We found reports of only 5 other GVHD cases after kidney transplantation. Several risk factors are associated with GVHD, such as transfer of graft lymphocytes, donor HLA homozygosity, and a relationship between recipient immunogenicity and immunosuppression. In this case, detection led to early diagnosis of donor-derived GVHD due to passenger lymphocyte syndrome. It is important keep GVHD in mind and to understand its risk factors as the mortality rate is high.
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Affiliation(s)
- Taigo Kato
- Department of Urology, Osaka General Medical Center, Osaka, Japan.
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27
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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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Selbst MK, Ahrens WA, Robert ME, Friedman A, Proctor DD, Jain D. Spectrum of histologic changes in colonic biopsies in patients treated with mycophenolate mofetil. Mod Pathol 2009; 22:737-43. [PMID: 19329937 DOI: 10.1038/modpathol.2009.44] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Mycophenolate mofetil, an immunosuppressive agent, is frequently used following bone marrow and solid organ transplantation. Diarrhea is a commonly seen side effect of mycophenolate mofetil, which may necessitate colonic biopsy in some patients. The histologic changes found in this setting have been reported to mimic self-limited colitis, graft-vs-host disease or inflammatory bowel disease in isolated case reports, and could pose diagnostic and management difficulties. The goal of this study is to define the spectrum of histologic changes in colonic biopsies associated with mycophenolate mofetil usage. All solid organ transplant patients who received mycophenolate mofetil and underwent colonic biopsy for gastrointestinal symptoms from 1999 to 2007 were included in the study. Patients who did not receive mycophenolate mofetil were used as controls. Various histologic features including architectural distortion, apoptosis, inflammatory infiltrate, Paneth cell metaplasia and mucin depletion were subjectively evaluated and scored (scale: 0-3) by two independent reviewers in a blinded fashion. Forty solid organ transplant patients underwent colonic biopsy for gastrointestinal symptoms during the study period. Biopsies from 69% of patients on mycophenolate mofetil showed histologic changes. Apoptosis (41%) and architectural distortion (66%) were seen more frequently in patients receiving mycophenolate mofetil as compared to the control group (13%). The histologic changes in patients receiving mycophenolate mofetil were categorized as normal/near normal (31%), inflammatory bowel disease-like (28%), graft-vs-host disease-like (19%), ischemia-like (3%) and self-limited colitis-like (16%) changes. Of the controls, only one patient showed a graft-vs-host disease-like histologic pattern. In conclusion, histologic changes are frequently associated with mycophenolate mofetil use and can resemble self-limited colitis, graft-vs-host disease and inflammatory bowel disease leading to diagnostic difficulties. Increased awareness of the histologic spectrum of mycophenolate mofetil-induced changes is required by the pathologist to avoid diagnostic errors.
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Affiliation(s)
- Megan K Selbst
- Department of Pathology, Yale University School of Medicine, New Haven, CT 06520-8023, USA
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29
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Worel N, Bojic A, Binder M, Jaksch P, Mitterbauer G, Streubel B, Thalhammer F, Staudinger T, Laczika KF, Locker GJ. Catastrophic graft-versus-host disease after lung transplantation proven by PCR-based chimerism analysis. Transpl Int 2008; 21:1098-101. [PMID: 18764830 DOI: 10.1111/j.1432-2277.2008.00754.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Acute graft-versus-host disease (GvHD) is a rare complication after solid organ transplantation. We describe a 52-year-old female developing neutropenia and fever 48 days after single lung transplantation for chronic obstructive pulmonary disease. Bone marrow (BM) biopsy suggested drug-induced marrow failure, so immunosuppression was reduced. Five days later a maculopapular skin rash was observed, progressing to a generalized erythema with desquamation. Skin biopsy was suspectable for GvHD, so immunosuppression was re-initiated. PCR-based chimerism analysis of BM revealed 78% donor cells. Intensified immunosuppression resulted in temporary improvement, but BM aplasia recurred and the patient experienced severe GvHD of gut and liver. Despite extensive immunosuppression the patient died from multi-organ failure 99 days after transplantation. This report describes the occurrence of neutropenia as an early presenting sign of acute GvHD after lung transplantation. We therefore recommend incorporating GvHD in the differential diagnosis of neutropenia after solid organ transplantation, calling for early chimerism analyses.
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Affiliation(s)
- Nina Worel
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria.
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30
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Pintar T, Pleskovič A, Alessiani M, Abbiati F, Milutinović A, Petrovič D, Pogačnik M, Zorc-Pleskovič R. Skin biopsies predict acute graft-versus-host disease after small bowel transplantation in pigs. Acta Vet Hung 2007; 55:533-41. [PMID: 18277712 DOI: 10.1556/avet.55.2007.4.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Intestinal transplantation is being increasingly performed to treat patients with irreversible intestinal failure. The major cause of intestinal graft failure is graft-versus-host disease (GVHD) that represents a life-threatening complication after small bowel transplantation (Itx). The purpose of this study was to assess the diagnostic and prognostic value of skin biopsy histological changes for acute GVHD after Itx in pigs. Thirty-four Large White pigs were divided into three groups: Group 1 with Itx only, Group 2 with Itx and donor bone marrow infusion (Itx BM) and Group 3 (control group - before the operation). Animals received tacrolimus-based immunosuppression from day 0 to day 30 postoperatively. Skin and small bowel biopsies were histologically assessed, analysed and classified from grade 1 to 4 on postoperative days 15, 30, 45 and 60. There was a strong correlation between the histological grading values of skin biopsy changes and the histological grading values of small bowel biopsy changes (Kendall's tau_b is 0.855 for the Itx group and 0.730 for the Itx BM group). The significant correlation found between skin and small bowel histological changes suggests the prognostic value of skin biopsies after Itx. In conclusion, our findings emphasise the diagnostic and prognostic value of skin biopsy analysis for acute GVHD after Itx.
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Affiliation(s)
- Tadeja Pintar
- 1 Medical Centre Ljubljana Abdominal Surgery Department Ljubljana Slovenia
| | - A. Pleskovič
- 1 Medical Centre Ljubljana Abdominal Surgery Department Ljubljana Slovenia
| | - M. Alessiani
- 2 University of Pavia and IRCCS Fondazione Policlinico San Matteo Department of Surgery Pavia Italy
| | - Francesca Abbiati
- 2 University of Pavia and IRCCS Fondazione Policlinico San Matteo Department of Surgery Pavia Italy
| | - Aleksandra Milutinović
- 3 University Ljubljana Institute of Histology and Embryology, Medical Faculty Korytkova 2 1105 Ljubljana Slovenia
| | - D. Petrovič
- 3 University Ljubljana Institute of Histology and Embryology, Medical Faculty Korytkova 2 1105 Ljubljana Slovenia
| | - M. Pogačnik
- 4 Veterinary Faculty Institute of Pathology, Forensic and Administrative Veterinary Medicine Ljubljana Slovenia
| | - Ruda Zorc-Pleskovič
- 3 University Ljubljana Institute of Histology and Embryology, Medical Faculty Korytkova 2 1105 Ljubljana Slovenia
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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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32
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33
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Chitlur M, Abella E, Singh TP, Savaşan S. Severe neutropenia and thrombocytopenia following cardiac transplantation in a child. Pediatr Transplant 2005; 9:94-6. [PMID: 15667619 DOI: 10.1111/j.1399-3046.2004.00233.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Hematological complications have been occasionally described after cardiac transplantation. We are reporting a 5-yr-old child who developed sequential severe neutropenia and thrombocytopenia following cardiac transplantation while on tacrolimus-based immune suppression therapy. There was no improvement in blood counts following a change in immune suppression to cyclosporine A. The neutropenia was associated with a maturation arrest in the bone marrow. The occurrence of thrombocytopenia coincided with rising anti-herpes virus 6 IgG titers suggesting a possible contributory role. Neutropenia resolved following treatment with rituximab, and the thrombocytopenia responded to Dapsone therapy eventually. This case points out the potential multifactorial pathogenesis of cytopenias following cardiac transplantation with differing response to various immune suppressive therapies.
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Affiliation(s)
- Meera Chitlur
- Division of Hematology/Oncology, Children's Hospital of Michigan, Detroit, MI 48201, USA
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