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Kidney Week

Abstract: PO2429

Graft vs. Host Disease Following Simultaneous Liver-Kidney Transplant

Session Information

Category: Trainee Case Report

  • 1902 Transplantation: Clinical

Authors

  • Syed, Bushra, Cleveland Clinic, Cleveland, Ohio, United States
  • Hassanein, Mohamed, Cleveland Clinic, Cleveland, Ohio, United States
  • Nurko, Saul, Cleveland Clinic, Cleveland, Ohio, United States
Introduction

Solid organ transplant associated GVHD is uncommon with an incidence of 0.5 to 2%. Risk factors include donor HLA homozygosity, younger donor, recipient age >50 years and sex mismatch. We present a case of GVHD following a simultaneous liver kidney transplant (SLK).

Case Description

A 64-year-old female with NASH cirrhosis and CKD due to diabetic nephropathy underwent SLK from a 38-year-old male deceased donor. The pair had 3 HLA AB mismatches and 1 DR mismatch. A total of 3.5mg/kg of thymoglobulin (ATG) was used for induction. Renal and liver parameters were stable at discharge on a maintenance tacrolimus, mycophenolate and prednisone. She was readmitted after 1-month with diarrhea and fever. Infectious work up was unrevealing. She developed a maculopapular rash, mucositis and pancytopenia. Skin biopsy showed grade 2 acute GVHD. Donor lymphocyte chimerism in peripheral blood confirmed diagnosis of GVHD with 65% donor T cells, 10% donor CD8 cells and 42% donor natural killer (NK) cells. Treatment with high dose steroids and ATG was ineffective with worsening in CD8 and NK cell donor chimerism to 91% and 52% respectively. Weekly infliximab (INX) was introduced complicated by development of enterococcal bacteremia. Clinical improvement was seen after three doses INX, however there was a lag of several weeks before an improvement in donor chimerism. Six months later her hematological, renal and liver parameters remained stable, chimerism study showed <5% T cells, CD8 cells and NK cells and a protocol renal biopsy showed no evidence of GVHD associated denovo glomerulonephritis.

Discussion

The non-specific presentation of GVHD with rash, cytopenias and diarrhea leads to delayed diagnosis and high mortality. Detection of donor chimerism through short tandem repeat sequences is used to establish diagnosis and monitor response to treatment. Treatment options include high dose steroids with ATG, TNF a inhibitors or IL-2 antagonists. Adequate immunosuppression has to be balanced with risk of infection and timely use of empiric antibiotics and antifungals is recommended. Despite treatment, rapid progression to marrow aplasia, sepsis and multisystem failure ensues with an estimated mortality of >75%. Further studies are required to better understand this rare complication and explore novel treatments to improve outcomes.