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Xu Z, Otrock ZK. Extracorporeal photopheresis: A case of graft-versus-host-disease and hemophagocytic lymphohistiocytosis following liver transplantation. Transfusion 2022; 62:2409-2413. [PMID: 36082758 DOI: 10.1111/trf.17096] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/15/2022] [Accepted: 08/16/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Graft-versus-host-disease (GVHD) is one of the rare complications following liver transplantation. We report on the efficacy and safety of extracorporeal photopheresis (ECP) in managing GVHD and hemophagocytic lymphohistiocytosis (HLH) after liver transplantation. CASE REPORT The patient is a 63-year-old male with hepatitis B cirrhosis who underwent liver transplantation. Three weeks after transplant, he presented with fever, diarrhea, and poor appetite. The patient also had bilateral blanchable erythematous patches on his palms, biopsy of which was suggestive of GVHD. The patient continued to have high-grade fever with altered mental status. CBC showed pancytopenia. Liver function examination was normal. Patient was started on methylprednisolone. Additional laboratory analysis showed high ferritin (>15000 ug/L), triglycerides (280 mg/dl), and low fibrinogen (80 mg/dl). Chimerism analysis using short tandem repeat (STR) PCR confirmed the diagnosis of GVHD. Marrow biopsy showed hemophagocytosis. The patient fulfilled the HLH-2004 diagnostic criteria. He was kept on tacrolimus and steroids and was started on etanercept and ECP. After the first two cycles of ECP (one cycle defined as the weekly two procedures of ECP), the patient reported improvement of symptoms. He tolerated ECP well. His labs improved during the course of treatment, until his peripheral blood STR showed 100% recipient DNA. He was discharged after the fourth cycle of ECP to receive the remaining treatments as outpatient. At one year follow-up, the patient is asymptomatic with no evidence of GVHD or HLH. DISCUSSION ECP in combination with immunosuppressive therapy and etanercept was safe and efficient in managing GVHD and HLH following liver transplantation.
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Affiliation(s)
- Zhengfan Xu
- Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Zaher K Otrock
- Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, Michigan, USA
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Szczepanik A, Choi D, Brady B, Chandran MM, Diamond A, Do V, Fredrick S, Kaiser T, Khalil K, Laub MR, Leino A, Park JM, Pierce D, Rendulic T, Wiegel JJ, Fose J, Jorgenson MR. The use of non-transplant biologics in solid organ transplant recipients: A practical review for the frontline clinician. Clin Transplant 2022; 36:e14743. [PMID: 35690919 DOI: 10.1111/ctr.14743] [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: 02/18/2022] [Revised: 05/09/2022] [Accepted: 06/01/2022] [Indexed: 11/27/2022]
Abstract
Biologics have become the forefront of medicine for management of autoimmune conditions, leading to improved quality of life. Many autoimmune conditions occur in solid organ transplant (SOT) recipients and persist following transplant. However, the use of biologics in this patient population is not well studied, and questions arise related to risk of infection and adjustments to induction and maintenance immunosuppression. Guidelines have been published highlighting management strategies of biologics around the time of elective surgical procedures, but this is not always feasible in urgent situations, especially with deceased donor transplantation. The aim of this review is to summarize the current literature regarding the use of these agents in solid organ transplant recipients, and specifically address induction and maintenance immunosuppression, as well as the need for alternative infective prevention strategies to create a practical reference for the frontline clinician, when faced with this complex clinical scenario.
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Affiliation(s)
- Amanda Szczepanik
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - David Choi
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, USA
| | | | | | | | - Vincent Do
- Department of Pharmacy, Yale New Haven Hospital, New Haven, Connecticut, USA
| | | | | | | | - Melissa R Laub
- Department of Pharmacy, Augusta University Medical Center, Augusta, Georgia, USA
| | - Abbie Leino
- Department of Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Jeong M Park
- Department of Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Dana Pierce
- Department of Pharmacy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | | | | | - Jillian Fose
- Department of Pharmacy, UW Health, Madison, Wisconsin, USA
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