Graft-versus-host disease as an unusual complication following liver transplant
Authors:
L. Husová 1; V. Mejzlík 1; H. Jedličková 2; T. Ostřížek 1; M. Kuman 1; S. Štěpánková 1; V. Žampachová 3; P. Němec 1
Authors‘ workplace:
Centrum kardiovaskulární a transplantační chirurgie, Brno
1; I. dermatovenerologická klinika LF MU a FN U sv. Anny v Brně
2; I. patologicko-anatomický ústav LF MU a FN u sv. Anny v Brně
3
Published in:
Gastroent Hepatol 2012; 66(2): 109-115
Category:
Hepatology: Case Report
Overview
417 orthotopic transplants were carried out at the Brno transplant centre between 2 February 1983 and 1 December 2011. Graft-versus-host disease (GVHD) was diagnosed in a single case (0.24%). The authors describe the case of a 59-year-old woman who underwent liver transplant due to secondary biliary cirrhosis following iatrogenic damage of the ductus choledochus during cholecystectomy. Following the liver transplant, the patient developed skin exanthem accompanied by diarrhoea, followed by leukopenia and septic shock development. The GVHD diagnosis was tested by skin biopsy and supported by determining the presence of the proportion of donor cells in the recipient's peripheral blood (chimerism). The treatment involved applying high doses of glucocorticoids, maintaining the lowest possible effective levels of tacrolimus, administering immunoglobulins, anti-CD25 mAbs, and symptomatic therapy (factor stimulating granulocytes, antibiotics and antivirotics). Despite the very complicated course, the patient improved both subjectively and objectively and the GVHD symptoms gradually subsided. However, the condition was accompanied by a distinctive leukopenia with sepsis developed. The above-mentioned therapy resulted in a gradual improvement of both the clinical condition and the laboratory results as well as in the discharge after 77 days from the transplant. However, after another 10 days skin symptoms reoccurred, which subsided again after increasing glucocorticoids and reducing the dose of calcineurin inhibitors. This condition was accompanied by neither leukopenia nor sepsis. The patient had recovered again by the 252nd day after the transplant with heart failure involving bioptically proven viral myocarditis. The patient is now 10 months after the liver transplant without any GVHD clinical symptoms and with good functioning of the liver graft.
Key words:
exanthem – graft-versus-host disease – liver transplant
Sources
1. Burdick JF, Vogelsang GB, Smith WJ et al. Severe graft-versus-host disease in a liver-transplant recipient. N Engl J Med 1988; 318(11): 689–691.
2. Smith DM, Agura E, Netto G et al. Liver transplant-associated graft-versus-host disease. Transplantation 2003; 75(1): 118–126.
3. Taylor A, Sudhindran S, Key T et al. Monitoring systemic donor lymfocyte microchimerism to aid the differential diagnosis of graft versus host disease following liver transplantation. Transplantation 2004; 77(3): 441–446.
4. Kohler S, Pascher A, Junge G et al. Graft versus host disease after liver transplantation – a single center experience and review of literature. Transpl Int 2008; 21(5): 441–451.
5. Mayer J, Cetkovský P, Krejčí M. Steroid-rezistentní akutní reakce štěpu proti hostiteli (GVHD). Transfuze hematol dnes 2007; 13(4): 192–199.
6. Taylor AL, Gibbs P, Bradley JA. Acute graft versus host disease following liver transplantation: The enemy within. Am J Transplant 2004; 4(4): 466–474.
7. Ratanatharathorn V, Ayash L, Lazarus HM et al. Chronic graft-versus-host disease: clinical manifestation and therapy. Bone Marrow Transplant 2001; 28(2): 121–129.
8. Whitington PF, Rubin CM, Alonso EM et al. Complete lymphoid chimerism and chronic graft-versus-host disease in an infant recipient of a hepatic allograft from an HLA-homozygous parenteral living donor. Transplantation 1996; 62(10): 1516–1519.
9. Jonsson JR, Hogan PG, Thomas R et al. Peripheral blood chimerism following human liver transplantation. Hematology 1997; 25(5): 1233–1236.
10. Schlitt HJ, Kanehiro H, Raddatz G et al. Persistance of donor lymphocytes in liver allograft recipients. Transplantation 1993; 56(4): 1001–1007.
11. Schmuth M, Vogel W, Weinlich G et al. Cutaneous lesions as the presenting sign of acute graft-versus-host disease following liver transplantation. Br J Dermatol 1999; 141(5): 901–904.
12. Jamienson NV, Joysey V, Friend PJ et al. Graft-versus-host disease in solid organ transplantation. Transpl Int 1991; 4(2): 67–71.
13. Vogelsang GB, Lee L, Bensen-Kennedy DN. Pathogenesis and treatment of graft-versus--host disease after bone marrow transplant. Ann Rev Med 2003; 54: 29–52.
14. Hings IM, Filipovich AH, Miller WJ. Prednisolone therapy for acute graft-vs-host disease: short- vs. long-term treatment. A prospective randomised trial. Transplantation 1993; 56(3): 577–580.
15. Martin PJ, Schoch G, Fisher LA. Retrospective analysis of therapy for acute graft--vs-host disease: initial treatment. Blood 1990; 76(8): 1464–1472.
16. Dunn SP, Krueger LJ, Butani L et al. Late onset of severe graft-versus-host disease in a pediatric liver transplantation. Transpl Int 1998; 11: S383–S384.
17. Roberts JP, Ascher NL, Lake J et al. Graft vs. Host disease after liver transplantation in humus: a report of four cases. Hepatology 1991; 14(2): 274–281.
18. Sundhidran S, Taylor A, Delriviere L et al. Treatment of graft-versus-host disease after liver transplantation with basiliximab followed by bowel resection. Am J Transpant 2003; 3(8): 1024–1029.
19. Massenkeil G, Rackwitz S, Genvresse I et al. Basiliximab is well tolerated and effective in the treatment of steroid refractory acute graft-versus-host disease after alogenetic stem cell transplantation. Bone Marrow Transplant 2002; 30(12): 899–903.
20. Willenbacher W, Basara N, Blau IW et al. Treatment of steroid refractory acute and chronic graft-versus-host disease with daclizumab. Br J Haematol 2001; 112(3): 820–823.
21. Przepiorka D, Kernan NA, Ippoliti C et al. Daclizumab, a humanized anti-interleukin-2 receptor alpha chain antibody, for treatment of acute graft-versus-host disease. Blood 2000; 95(1): 83–89.
22. Kobbe G, Schneidr P, Rohr U et al. Treatment of severe steroid refractory acute graft-versus-host disease with infliximab, a chimeric human/mouse anti TNF alpha antibody. Bone Marrow Transplant 2001; 28(1): 47–49.
23. Jacobsohn DA, Hallick J, Anders V et al. Infliximab for steroid-refractory acute GVHD. A case series. Am J Hematol 2003; 74(2): 119–124.
24. Lehner F, Becker T, Sybrecht L et al. Successful outcome of acute graft-versus--host disease in a liver allograft recipient by withdrawal of immunosuppression. Transplantation 2002; 73(2): 307–310.
25. Cooke KR, Gerbitz A, Crawford JM et al. LPS antagonism reduces graft-versus-host disease and preserves graft-versus-leukemia activity after experimental bone marrow transplantation. J Clin Invest 2001; 107(12): 1581–1589.
26. Williamson E, Garside P, Bradley JA et al. Neutralizing IL-12 during induction of murine acute graft-versus-host disease polazizes the cytosine profile toward a Th2-type alloimmune response and confers long term protection from disease. J Immunol 1997; 159(3): 1208–1215.
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Paediatric gastroenterology Gastroenterology and hepatology SurgeryArticle was published in
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