Graft-versus-host disease following deceased donor liver transplant
Putchakayala K, Skorupski S, Farhan S, Chaffins M, Ilias S, Pahari H, Collins K, Nagai S, and Abouljoud M. Graft-versus-host disease following deceased donor liver transplant. Am J Transplant 2017; 17:783-784.
Am J Transplant
We reviewed our institutional experience with graft-versus-host disease (GVHD) following orthotopic liver transplantation (OLT). All OLT from 10/1/2013-10/1/2016 were reviewed. Five cases of GVHD were identified. Recipient-Donor characteristics (Table presented). All had NASH cirrhosis. Donor-recipient age difference was 8 to 32 years. Despite donor BMI and liver weight 2.0-2.4kg, biopsies found <10% macrosteatosis. All received anti-thymocyte globulin (ATG) induction with 1.5mg/kg in three divided doses, corticosteroid taper, mycophenolate mofetil, and tacrolimus (FK). Clinical courses (Table presented). Diagnosis occured 22 to 68 days after OLT, using a combination of skin biopsy and presence of donor-derived DNA via short-tandem repeats (STR). The lowest absolute lymphocyte count (ALC) was 0 cells/cubic mm in the majority of patients. All were treated with high-dose corticosteroid and reduction in FK goal to ∼4mg/dL in the absence of rejection. Etanercept was used for three cases with suspected bone marrow involvement, and photopheresis was used in two refractory cases. Three patients elected for hospice in the setting of infection and expired with functional grafts. GVHD is multi-factorial, combining donor lymphocyte burden (liver weight > 2.0kg) and recipient lymphocyte depletion (ALC 0) to allow donor lymphocytes to persist and activate. A high level of suspicion and prompt biopsy/DNA testing are essential. Treatment modalities must be balanced with the risks of rejection and infection, but remission and survival are possible.