Effects of immunosuppression regimens on occurrence of graft versus host disease in liver transplantation. an analysis of UNOS registry
Am J Transplant
Background: Graft-versus-host disease (GVHD) after liver transplant is a rare complication. This study aimed to analyze the UNOS registry to identify risk factors for fatal GVHD, focusing on effects of immunosuppression regimens. Methods: We used the UNOS registry. All liver transplant and liver-kidney transplant patients between 2002 and 2018 were analyzed. An endpoint was set as mortality due to GVHD. Patients who died within 30 days after transplant were excluded. We analyzed associations between GVHD and immunosuppression regimens, including induction and maintenance, along with other recipient and donor characteristics. Multivariate Cox regression model was used. Results: A total of 85033 patients were eligible. There were 128 patients (0.2%) who died of GVHD. Rabbit-antithymocyte globulin (rATG), Basiliximab, and Rituximab were used as induction in 8406 (9.9%), 13173 (15.5%), and 1802 (2 .1%), and Mycophenolate and Azathioprine were used as maintenance in 56360 (66.2%) and 1443 (1.7%), respectively. When comparing between groups with and without induction on multivariate analysis, the induction group showed a significantly higher risk for GVHD (hazard ratio [HR], 1.60; P=0.02). When immunosuppression regimens were separately included in a multivariate model, Basiliximab (HR, 1.93; P=0.003) remained as independent risk factors, along with recipient-donor age discrepancy (HR, 1.03 [per year]; P<0.001). Mycophenolate maintenance showed a protective effect (HR, 0.56; P=0.002) and rATG was not associated with GVHD (HR, 0.95; P=0.88). Conclusions: Avoiding Basiliximab induction and adding Mycophenolate to maintenance may be favorable to decrease a risk of GVHD.