Graft-Versus-Host Disease after Liver Transplantation
Purpose: Graft-Versus-Host Disease (GVHD) is a rare (0.1∼2%) but severe complication after liver transplantation (LT). It is the most lethal complication after LT and there are currently no effective preventive or therapeutic measures available. Approximately 90 such cases have been reported in the literature, but only one case has been reported in Korea.
Methods: We performed a retrospective analysis of 767 patients who underwent LT (living donor : deceased donor=554 : 213) at Seoul National University Hospital, Korea from 1998 to 2009. Four patients (4/767, 0.52%) with histologically proven GVHD were found. The diagnosis of GVHD was made according to observing macrochimerism in the peripheral blood and the affected tissue biopsy.
Results: Four patients underwent LT due to Hepatitis B virus-related liver cirrhosis and two of these patients had coexisting hepatocellular carcinoma. Three patients received livers from deceased donors and one received a liver from a live donor. All their blood matching were identical. The first diagnosed case underwent human leukocyte antigen (HLA) typing only after LT and it showed complete one-way donor-recipient HLA matching. The onset of GVHD occurred between 10 days and 55 days after LT. All the patients developed high-grade fever, skin rash, neutropenia, diarrhea and the main signs and symptoms related to GVHD. All the patients died because of sepsis despite intensive treatment.
Conclusion: GVHD after LT is an extremely rare and fatal complication and it is difficult to diagnose. Therefore, we should perform pre-transplant HLA matching and try to establish an early diagnosis for patients who are clinical suspicious of having GVHD. Further study in this area is needed and physicians need to be alert to detect this malady.
Hyeyoung Kim, M.D., Nam-Joon Yi, M.D., Kyung-Suk Suh, M.D., Geon Hong, M.D., Young Min Jeon, M.D., Kwang-Woong Lee, M.D., Myung Hee Park, M.D.
1, Eung-Ho Cho, M.D.
2, Kuhn Uk Lee, M.D.
Department of Surgery, Seoul National University College of Medicine,
1Department of Clinical Pathology, Seoul National University College of Medicine,
2Department of Surgery, Korea Cancer Center Hospital
Corresponding Author Kyung-Suk Suh
Department of Surgery, Seoul National University College of Medicine, 28, Yeongeon-dong, Jongno-gu, Seoul 110-744, Korea
Tel: +82-2-2072-2312 Fax: +82-2-766-3975
E-mail: [email protected]
Key Words : Graft-versus-host disease, GVHD, Liver transplantation, Chimerism
Received: 2010. 9. 4.
Accepted: 2010. 10. 11.
Introduction
Graft-Versus-Host disease (GVHD) is the most fatal complication of bone marrow (BM) and solid organ transplantation. It involves activation of donor T lympho- cytes by antigen-presenting cells in the transplanted patients, causing a local inflammatory reaction.1 The main target organs of GVHD are the skin and mucous membranes, gastrointestinal tract, the liver, and the BM.1,2
The clinical course begins with fever or skin rash as an early sign, followed by diarrhea, pancytopenia, overwhel- ming sepsis, and death as a consequence of BM invol- vement.2,4-6 The basic function of the transplanted liver remains unaffected.
Although it is a known complication of stem cell transplantation, GVHD after LT has also reported as a fatal complication.3 Acute GVHD usually occurs within 2 to 8 weeks of LT.1-4 The early symptoms of GVHD after LT are non-specific, and hence the diagnosis is difficult.2 The
Table 1. Characteristics of recipients and donors
Patient Age/Sex
Disease Type of LT (year)
ABO-Rh Cytotoxic
Antibody
HLA Miss-match
R D R D R D
1
2
3
4*
41/F
62/M
53/M
51/M
31/M
31/F
13/M
21/M
HBV-LC
HBV-LC, HCC
HBV-LC
HBV-LC, HCC
DDLT (2006) DDLT (2009) DDLT (2007) LDLT (2004)
B＋
A＋
O＋
B＋
B＋
A＋
O＋
B＋
(−)
(−)
NC
NC
A 2, 26 B 44, 58 DR 12, 14 A 2 B 13, 48 DR 12, 14 A 26, 33 B 58, 62 DR 12, 13 A 2 B 46, 51 DR 8, 4
11, 33 44, 54 1, 13 2, 24 48, 61 9, 14 24, 33 44, 51 12, 15 2 46 8
2 1 2 0 1 1 1 2 1 0 0 0 R=recipient; D=donor; F=female; M=male; HBV-LC=hepatitis B virus-related liver cirrhosis; HCC=hepatocellular carcinoma; NC=not checked; *One-way donor-recipient HLA matching
proof of macrochimerism (＞1% chimerism in peripheral blood), skin biopsy, together with clinical symptoms indicative of GVHD are a key to early detection of GVHD.2,5-7
Approximately, 90 cases of GVHD after LT have been reported in the literature since 19871 and so far only one such case in Korea has been reported in the literature.3 In the following section, the clinical outcomes of the four patients with acute GVHD after LT at our center, is presented and discussed (Including the first GVHD case in Korea in 2007 reported in the literature).
Methods
An analysis of 767 patients who underwent liver trans- plantation (living donor LT (LDLT) : deceased donor LT (DDLT)=554 : 213) between 1988 and 2009 at the Seoul National University Hospital in Korea was performed.
Patient’s medical records were retrospectively reviewed.
Among them, histologically documented GVHD was found in four patients (4/767, 0.52%). LT had been performed due to hepatitis B virus-related liver cirrhosis (n=4) and two of these patients had a coexisting
hepatocellular carcinoma (HCC) (n=2). Three patients received transplants from a deceased donor, and one from a living-related donor, his son. Median age of the patients was 51.5 years (range 41∼62 years; male : female=3 : 1) (Table 1).
Donor-recipient HLA-class I and II typing was performed by serological and/or molecular genetic methods before transplantation, except in one case which the typing was done at the time of clinical suspicion of GVHD.
In all the patients, a quantitative short tandem repeat (STR) test was performed to confirm macrochimerism at the time of clinical suspicion of GVHD. DNA from the recipient was obtained from peripheral blood samples, once pre-transplant and then at the time of suspicion of GVHD.
Donor and recipient DNA were distinguished by using template DNA and polymerase chain reaction (PCR) ampli- fication for STR chromosomal loci. STR profiles of recipient cells before transplantation were compared with those after transplantation. The difference shows the amount of the donor cells calculated by comparing the peak areas of the donor and the recipient signals.7
Table 2. Clinical course after onset of GVHD and outcome
Patient Onset (POD)
Clinical symptom/sign (POD)
BM biopsy (POD)
Bowel biopsy (POD)
Skin biopsy (POD)
Chimerism (STR test)
Therapy
Outcome (POD/day after onset), Neutro- COD
penia Fever Diar- rhea
Skin rash
Mixed chimeri- sm (POD)
Donor DNA in peripheral
blood (%) 1
2
3
4 10
10
40
55
＋ (10)
＋ (10)
＋ (58)
＋ (58)
＋ (10)
＋ (14)
＋ (40)
＋ (61)
＋ (17) -
＋ (44)
＋ (55)
＋ (18)
＋ (19)
＋ (58)
＋ (55)
Suppression (18) Suppression (14)
NC
NC
NC
NC
CMV colitis (60) CMV colitis (63)
Acute GVHD (20)
NC
Drug eruption (62) Toxic eryth- ema, Sugge- sting GVHD (110, 133)
＋ (21)
＋ (20)*
＋ (64, 70)
＋ (122)
98.3
96.4
32.2/52.1
10
Increase steroid Stop IS
Stop IS
Increase steroid
Dead (28/
18), d/t sepsis Dead (20/
10), d/t sepsis Dead (70/
31), d/t sepsis Dead (138/
83), d/t sepsis
POD=post-operative day; BM=bone marrow; COD=cause of death; NC=not checked; d/t=due to; CMV=cytomegalo virus; STR=short tandem repeat; IS=immunosuppressant; *Examined at the day of death
Fig. 1. Skin rash in patient 4.
Results
Four patients were diagnosed (0.52%) and all died due to the complication of GVHD (4/4, 100%) at our center.
All their blood matching were identical (Table 1). But HLA-matching in the first diagnosed case (LDLT) of
homozygous donor with one-way donor-recipient HLA matching showed HLA homozygosity as a known high risk factor for GVHD. In this case HLA-typing was carried out after the transplantation and the onset of GVHD.3 In addition, all the patients had received basiliximab induction (20 mg i.v. qd intra-operatively on post-operative day (POD) 0 and POD 4). Basal immunosuppression consisted of tacrolimus and steroids.
Onset of GVHD occurred between POD 10 and POD 55 (Table 2). The patients developed high-grade fever, skin rash (Fig. 1), neutropenia, gastrointestinal symptoms of diarrhea, the signs and symptoms related to GVHD.
Neutropenia and fever were the first symptoms in three cases and one patient developed gastrointestinal symptoms of diarrhea and skin rash as the initial symptoms. All the patients developed high-grade fever, skin rash, BM suppression and severe neutropenia. In three of these patients there was an accompanying diarrhea.
BM biopsy was performed in two patients with neutropenia as the initial symptom on POD 10. Bowel
Fig. 2. Skin biopsy of patient 1 (A, On POD 20, H & E stain, ×400) and patient 4 (B, On POD 110, H&E stain, ×400). The findings are consistent with GVHD: Perivascular lymphocyte infiltration (long tailed arrow), basal vacuolar change (arrow head), sparse lymphocytic infiltration of the dermis (short tailed arrow).
mucosal biopsy was performed in the other two patients who were suffering subacute clinical course and diarrhea.
Skin biopsy was performed in three cases and two of them were diagnosed with GVHD (Fig. 2). Macrochimerism was confirmed in all the patients. Donor DNA in peripheral blood of patient #1 and #2 showed 98.3% and 96.4% in the critical course of acute GVHD. In patient #3 and #4 of subacute GVHD, donor DNA in peripheral blood showed 12.2% and 10.0% respectively (Table 2).
After the suspicion or diagnosis of GVHD after LT, the previously prescribed immunosuppressant was tried to reduce or quit (Table 2). Also, their steroid doses were changed in many ways. One patient was treated with methylprednisolone (80 mg i.v. qid for 4 days) as augmen- tation of baseline immunosuppression, in the other two patients reduction or conversely an increase in the steroid dose was tried out. The remaining one patient received unchanged steroid therapy because of his deleterious and rapidly deteriorating health condition.
All the patients died because of sepsis and multi-organ failure between 10 and 83 days after the onset of suspected GVHD (mean 35.5 days after onset) (Table 2).
Discussion
GVHD is a life-threatening complication after LT. GVHD involves activation of donor T lymphocytes by anti- gen-presenting cells in the transplanted patients, causing an alloreactive T-cell response to recipient tissues mediated by cytotoxic T cells and inflammatory cytokines.1 The most important antigen-presenting cells are HLA and minor histocompatibility antigens,8 but up till now, their mecha- nisms are still unclear. Although GVHD can affect up to 50% of patients after hematopoietic stem cell transplan- tation, the incidence of GVHD after LT is rare, 0.1 to 2%1,5,9,10 and the mortality rate is more than 90% in the recent literature.5,11-13
As an estimated number of 109∼1010 donor lymphoid cells are transplanted together with a liver graft, chimerism regularly occurs over a period of 3∼4 weeks after LT.
Thus, GVHD predominantly occurs in the first few weeks after LT7 and acute GVHD usually occurs within 2 to 8 weeks after LT.1-4 In this study, there have been two cases of acute GVHDs and two cases of subacute GVHDs.
Two main risk factors for the development of GVHD after LT have been determined: HLA matching between the
donor and the recipient (like in the case of our patient
#4),3,5,14-16 and the recipient age.2,5,14 The risk of fatal GVHD following LDLT may depend on the number of loci with donor-dominant one-way HLA matching. Homozygous donor with one-way donor-dominant HLA matching at three loci should be excluded if possible, because of the very high risk of developing fatal GVHD.15 After patient #4 (the first GVHD case, LDLT), HLA-typing has been routinely carried out at our center before LT.3 The incidence of HLA homozygosity is variable among different ethnic groups. It is reported to be 1.6% among the Caucasian population, and 3.2% among blood donors in Japan.6,15
Recipient age is also a definite risk factor for developing GVHD after LT in adults and this is in keeping with acute GVHD after allogeneic stem cell transplantation where recipients older than 40 years are known to be at increased risk of severe GVHD.2,5 In our study, four recipients were all older than 40 years. With increasing age of the recipients, the risk for GVHD seems to rise. It was reported to be nine fold higher for recipients older than 65 years of age compared with younger recipients.7,11
In addition, the recipients with autoimmune hepatitis, alcoholic liver disease, HCC and associated glucose intolerance are at a high risk for developing GVHD. And donor liver steatosis is also a high risk factor.17 Underlying recipient immunodeficiency is a possible risk factor, but there is no certainty.2,17
The early symptoms of GVHD after LT are non-specific.
It is often misdiagnosed as
Clostridium difficile
colitis, CMV infection, drug allergies, or rejection.2 In the above cases, patient #3 and #4 showing subacute onset had CMV infections too.There are several tests to suspect GVHD: (1) biopsy of the skin rash; (2) detection of donor peripheral blood leukocytic chimerism; (3) microsatellite phenotype; (4) detection of donor HLA types in the peripheral blood, mucous membrane, or skin by PCR and (5) detection of donor lymphocytes using immunohistochemistry on the skin rash.10 However, so far there is lack of a highly
specific simple method. Macrochimerism, skin biopsy, clinical symptoms indicating GVHD are keys to early detection of GVHD.2,5-7 In a recent study, fluorescent
in situ
hybridization analysis using sex chromosome probes is another useful method to confirm GVHD after organ transplantation from a donor of the opposite sex. The authors suggest that it is a rapid and reliable test for confirming the diagnosis of GVHD in a peripheral blood or skin biopsy sample.6Once diagnosed with GVHD after LT, treatment remains a challenge. There is no standard approach or a specific proven treatment. Most patients die of MOF from GVHD or more commonly, from opportunistic infections caused by the augmented immunosuppression given to treat GVHD.1 Several approaches have been used in case reports and in small case series with variable responses: Reduction or removal of immunosuppression,9,11,14 increased immunosu- ppression or high-dose corticosteroids,2,4,9,11,13
anti-lympho- cyte drugs (anti-thymocyte globulin, anti-lymphocyte globu- lin, the monoclonal anti-lymphocyte agent OKT3),2,9,11,16,18
and anti-interleukin-2 antibodies (basiliximab, daclizu- mab).1,9,14 Reduction or removal of all immunosuppression has been attempted in only a small number of patients due to the concern for allograft rejection.1,14 The use of tumor necrosis factor-alpha inhibitors such as infliximab has been used for GVHD after stem cell transplantation with variable responses.19 The infusion of mesenchymal stem cells is being studied for the treatment of GVHD following allogeneic hematopoietic stem cell transplantation, with early encouraging results,20 and that might prove helpful in GVHD of solid-organ transplantation, but this remains an investigational approach.1
In summary, GVHD after LT has been extremely rare and difficult to diagnose. So besides its fatality, we have poor information about the frequency, course, treatment of GVHD after LT. For the prevention of GVHD after LT, pre-transplant work up including complete HLA-typing is essential in LDLT to avoid one-way donor-recipient HLA matching, the known high risk factor of GVHD. A suspicion
of early GVHD needs to be raised in patients showing symptoms consistent with GVHD, such as high-grade fever, skin rash, pancytopenia or diarrhea after LT. If an early diagnosis can be made by the tissue biopsy of the affected organs (skin, bowel mucosa, BM, etc.) and macrochi- merism by STR in peripheral blood, we have to isolate the patient, sterilize the patient’s environment, do skin care and control the infections actively. Effective and specific treatment for GVHD after LT should be studied more.
