Liver transplantation for severe hepatic graft-versus-host disease: An analysis of aggregate survival data

Abstract

Graft-versus-host disease (GVHD) often occurs after bone marrow transplantation (BMT). GVHD may lead to cirrhosis or complete destruction of the bile ducts, and few effective treatment options exist for such cases. Orthotopic liver transplantation (OLT) has been described as an option, but to date the patient survival, graft survival, and GVHD recurrence rates after OLT have been unknown. Cases of OLT for GVHD were accumulated from several sources: (1) cases of OLT performed at a single institution, (2) the English-language medical literature, and (3) the United Network for Organ Sharing (UNOS) liver transplant registry. Descriptive data were derived from preand post-OLT information; survival analysis was performed using the Kaplan-Meier method. One case of OLT for GVHD after BMT was found at our institution, and another 6 cases were previously reported in the literature. Extrahepatic GVHD recurred in 2 cases, but no recurrence of hepatic GVHD was reported. The UNOS registry contained an additional 73 patients who underwent OLT for hepatic GVHD. The 1-and 5-year actuarial patient survival rates were 72.4% and 62.9%, respectively. Although 4 patients required retransplantation, no deaths or retransplants were attributed to the recurrence of hepatic GVHD. OLT is an effective treatment for hepatic GVHD after BMT or non-liver organ transplant. Longterm disease-free survival is obtainable in these cases, and recurrence of hepatic GVHD has not been reported. These findings suggest that OLT should be considered as an effective treatment option for cases of hepatic GVHD recalcitrant to medical treatment. (Liver Transpl 2005; 11:525-531.)G raft-versus-host disease (GVHD) is the most common complication of bone marrow transplantation (BMT) that affects patient survival and quality of life. 1 Chronic GVHD (defined as the onset of GVHD 100 days or more after BMT) is common, occurring in 30% to 50% of patients after matched related BMTs and 60% to 70% of patients after unrelated BMTs. 2 Although the overwhelming majority of GVHD cases occur after BMT, GVHD has been reported after organ transplantation, including small bowel, 3-6 liver, 7-13 kidney-pancreas, 14 and lung transplantation. 15,16 Corticosteroids are the most effective first-line treatment of GVHD after BMT, although corticosteroids alone lead to partial to complete remission in only 44% of patients. 17 Treatment of steroid-resistant GVHD after BMT includes calcineurin-inhibitors, methotrexate, 18 rapamycin, 19 mycophenolate mofetil, 20 thalidomide, 21 anti-tumor necrosis factor-␣ monoclonal antibody, or recombinant human soluble tumor necrosis factor-␣ receptor fusion protein. 22 These second-line treatments are often ineffective, however, and mortality among patients with steroid-resistant GVHD is 75% to 80%. 23 GVHD frequently causes mild liver injury after BMT but only rarely leads to end-stage liver disease or severe cholestasis. 24 Orthotopic liver transplantation (OLT) has previously been reported as a treatment for end-stage liver failure caused by GVHD re...

Solid Organ Transplantation After Allogeneic Hematopoietic Stem Cell Transplantation: A Retrospective, Multicenter Study of the EBMT

“…Numerous case reports describe the success of SOT after HSCT (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19) …”

Vanishing bile duct syndrome after allogeneic bone marrow transplantation: Is it the end of the road?

“…Unfortunately, at this stage, there is no established therapy other than liver transplantation. Some studies have reported successful liver transplantation from alive or deceased donors for intractable hepatic GVHD after HCT (17)(18)(19). Increased risk of relapse as a result of life-long immunosuppression after solid organ transplantation might be a major concern especially in highrisk patients.…”

Hepatic complications of hematopoietic cell transplantation

“…Treatment of chronic GVHD with corticosteroids and other immunosuppressants is less effective than such treatment for acute GVHD. Interestingly, orthotopic liver transplantation for severe GVHD is associated with a surprisingly high 5-year survival rate (62.9%) and lack of GVHD recurrence [36].…”