Contemporary outcomes and risk factors of acute graft-versus-host disease after liver transplant.
Markus J, Bukannan A, Kashat B, and Salgia R. Contemporary outcomes and risk factors of acute graft-versus-host disease after liver transplant. Am J Transplant 2017; 17:294.
Am J Transplant
Introduction: Acute graft-versus-host-disease (GVHD) is a rare complication of orthotopic liver transplant (LT) that has an estimated incidence of 0.1%-2% per year. This complication of OLT carries a high mortality and affects the skin, gastrointestinal tract, and bone marrow. GVHD usually presents within 6 weeks after LT. There is limited data on GVHD after LT, and prior reported risk factors include: older age of recipient, HLA A and B matching, > 20-year donor to recipient age difference, and alcoholic liver disease. We aimed to study outcomes of recent cases of acute GVHD after LT and explore potential risk factors due to the dearth of literature in this area. Methods: This is a retrospective, single center, review of patients who underwent LT between 2014-2016 and diagnosed with acute GVHD. GVHD was diagnosed both on clinical characteristics (fever, rash, diarrhea) as well as skin biopsy. Chimerism was tested on the skin biopsies. Descriptive statistics were utilized to analyze the outcomes and risk factors. Results: Seven patients were diagnosed with acute GVHD after LT during this time period. The mean time from transplant to diagnosis of GVHD was 42 days and all had a rash. The etiology of cirrhosis was 71% NASH, 14% Hepatitis C, and 14% alcoholic cirrhosis. An age gap of >20 years was identified in 86% of our patients. All patient had positive chimerism in the skin. HLA matching was compared between the donor and recipient; specifically A, B, C, DR, DQA1 and DQB1. Zero shared class 1 alleles were noted in 43% of patients and 25% of those did not share a class 2 allele. Of the class II alleles, 86% had one or more common alleles with the donor. Topical steroids were used in 14% of cases. IV solumedrol was used in 86% of patients. Etanercept was used on 57% of the patients and 50% of those were were also treated with photophoresis. Death occurred in 43%. Conclusion: In our study, risk factors for acute GVHD patients included a greater than 20 year age difference and HLA crossmatch. The majority of our patients shared at least one class 1 allele with their donor, however, we have a significant amount of class 2 allele crossmatch. The number of shared alleles did not appear to correlate with risk of developing GVHD after LT or intensity of treatment required. With early recognition and more aggressive treatment options, our data suggests that mortality for acute GVHD after LT may be improving over time. This needs to be confirmed with larger studies.