Graft-Versus-Host Disease After Simultaneous Pancreas–Kidney Transplantation: A Case Report and Review of the Literature

Rossi, Ana P.; Bone, B. A.; Edwards, Angelina; Parker, Michele; Santos, Rowena B. Delos; Hagopian, J.; Lockwood, Christina M.; Musiek, Amy; Klein, Christina L.; Brennan, Daniel C.

doi:10.1111/ajt.12862

Cited by 18 publications

(22 citation statements)

References 21 publications

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“…The mortality associated with GVHD is often as a consequence of sepsis 10,19 ; therefore, a strategy which does not increase the risk of this (by not increasing immunosuppression) is appealing. In contrast to other reports, 23 Reports of liver or pancreas transplant-associated GVHD suggest that older recipient age 6 and a high degree of HLA matching 24,25 are risk factors for the development of GVHD; however, in this case series, neither of these were associated with the disease. The degree of HLA mismatch at the A-, B-and DR-loci for each case sequentially was 1-2-2, 0-2-1, 1-0-0, 2-2-2, 2-0-2.…”

Section: Discussioncontrasting

confidence: 99%

“…Reports of liver or pancreas transplant‐associated GVHD suggest that older recipient age and a high degree of HLA matching are risk factors for the development of GVHD; however, in this case series, neither of these were associated with the disease. The degree of HLA mismatch at the A‐, B‐ and DR‐ loci for each case sequentially was 1‐2‐2, 0‐2‐1, 1‐0‐0, 2‐2‐2, 2‐0‐2.…”

Section: Discussioncontrasting

confidence: 69%

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Graft versus host disease after multivisceral transplantation: A UK center experience and update on management

Sharkey

Peacock

Russell

et al. 2018

Clinical Transplantation

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Graft versus host disease (GVHD) following transplantation of an intestine-containing graft occurs more frequently than with other solid organ transplants and is known to have a poor outcome. The presentation differs from other solid organ transplants, as the gastrointestinal tract is not involved following intestinal transplant. Diagnosis is based on clinical symptoms arising due to native tissue damage and the detection of donor T lymphocytes in circulating blood (T-cell chimerism). The ideal treatment strategy has not been defined, with advocates for both increased and decreased immunosuppression. We reviewed all cases of GVHD in an adult intestinal transplant center in the United Kingdom and report on management strategies of five cases and methods of detecting T-cell chimerism. The practice in our center has evolved with experience. The first two patients received an increase in immunosuppression, which was only successful in one case. Subsequently, reducing immunosuppression has been more effective. However, patients with bone marrow involvement have a poorer prognosis. We demonstrate successful treatment of GVHD after multivisceral transplant with a reduction in immunosuppression. This should be followed by vigilant graft surveillance and serial monitoring of the level of T-cell chimerism, with reintroduction of immunosuppression at the earliest sign of graft dysfunction.

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Section: Discussioncontrasting

confidence: 99%

Section: Discussioncontrasting

confidence: 69%

Graft versus host disease after multivisceral transplantation: A UK center experience and update on management

Sharkey

Peacock

Russell

et al. 2018

Clinical Transplantation

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“…This finding is in contrast to most previous studies, in which donor chimerism has been used as a biomarker for the development of GVHD. Some authors have gone as far as to propose that chimerism greater than 20% is highly specific for GVHD (28, 30). Nevertheless, we found that lymphoid lineage chimerism exceeding 40% occurred in a MVTx recipient without any signs of GVHD, providing the first documented evidence that chimerism of this magnitude can be achieved in multivisceral graft recipients without irradiation or bone marrow infusion and remain present for greater than one year even in the absence of pathology.…”

Section: Discussionmentioning

confidence: 99%

Macrochimerism in Intestinal Transplantation: Association With Lower Rejection Rates and Multivisceral Transplants, Without GVHD

Zuber

Rosen

Shonts

et al. 2015

American Journal of Transplantation

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Blood chimerism has been reported sporadically among visceral transplant recipients, mostly in association with graft-vs-host disease (GVHD). We hypothesized that a higher degree of mixed chimerism would be observed in multivisceral (MVTx) than in isolated intestinal (iITx) and isolated liver transplant (iLTx) recipients, regardless of GVHD. We performed a longitudinal prospective study investigating multilineage blood chimerism with flow cytometry in 5 iITx and 4 MVTx recipients up to one year post-transplant. Although only one iITx patient experienced GVHD, T-cell mixed chimerism was detected in 8 out of 9 iITx/MVTx recipients. Chimerism was significantly lower in the four subjects who displayed early moderate to severe rejection. Pre-formed high titer donor-specific antibodies, bound in vivo to the circulating donor cells, were associated with an accelerated decline in chimerism. Blood chimerism was also studied in 10 iLTx controls. Among non-sensitized patients, MVTx recipients exhibited greater T and B-cell chimerism than either iITx and iLTx recipients. Myeloid lineage chimerism was present exclusively among iLTx and MVTx (6/13) recipients, suggesting that its presence required the hepatic allograft. Our study demonstrates, for the first time, frequent T cell chimerism without GVHD following visceral transplantation and a possible relationship with reduced rejection rate in MVTx recipients.

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“…This case adds to two anecdotal descriptions of ECP in SOT‐GVHD, with only one survivor in three . (Worel and colleagues provided nine treatments after PTD 70, with death on Day 99 amid refractory chimerism [increasing from 78% to 91%]; Rossi and colleagues provided seven treatments, associated with chimerism reduction [52% to 13%] and survival.) This was our institution's second confirmed case of SOT‐GVHD and our first experience using ECP as a treatment.…”

Section: Discussionmentioning

confidence: 80%

“…4 Published data suggest mortality risk in proportion to chimerism and myelosuppression, with decedents exhibiting 20% to 95% chimerism (9/9 pancytopenic) versus survivors at 7% to 52% chimerism (2/3 nonpancytopenic; Table 1). [5][6][7][8][9][10][11][12] Whereas bone marrow transplantation (BMT)-GVHD follows the delivery of stem cells (SCs), SOT-GVHD does not, and mortality exceeds 75%, 13 nearing the 90% mortality rate seen in transfusionassociated GVHD (TA-GVHD), 14 with deaths likewise attributed to marrow failure and sepsis. The scale of additive harm (or counterbalancing benefit) from foregoing exposures to antirejection drugs in SOT patients is unresolved.…”

mentioning

confidence: 99%

Extracorporeal photopheresis in solid organ transplant–associated acute graft‐versus‐host disease

Houston¹,

Yan

Tinckam

et al. 2016

Transfusion

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Graft-Versus-Host Disease After Simultaneous Pancreas–Kidney Transplantation: A Case Report and Review of the Literature

Cited by 18 publications

References 21 publications

Graft versus host disease after multivisceral transplantation: A UK center experience and update on management

Graft versus host disease after multivisceral transplantation: A UK center experience and update on management

Macrochimerism in Intestinal Transplantation: Association With Lower Rejection Rates and Multivisceral Transplants, Without GVHD

Extracorporeal photopheresis in solid organ transplant–associated acute graft‐versus‐host disease

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