Graft Versus Host Disease After Liver Transplantation in Adults: A Case series, Review of Literature, and an Approach to Management.
Graft Versus Host Disease After Liver Transplantation in Adults: A Case series, Review of Literature, and an Approach to Management.
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DOI：
10.1097/tp.0000000000001406
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发表时间：
2016-12
期刊：
影响因子：
6.2
通讯作者：
Dunkelberg J
中科院分区：
文献类型：
--
作者：
Murali AR;Chandra S;Stewart Z;Blazar BR;Farooq U;Ince MN;Dunkelberg J
肝移植(LT)后移植物抗宿主病(GVHD)是一种致命的并发症，有关危险因素、诊断和处理的数据非常有限。我们报告了一系列的病例和对文献的全面回顾。系统地从移植后的GVHD报告和器官共享联合网络(UNOS)数据库中提取数据。进行组间比较。本文报告成人肝移植术后移植物抗宿主病156例。移植物抗宿主病发病的中位时间为28天。临床表现为皮疹(92%)、全血细胞减少(78%)和腹泻(65%)。肝移植后移植物抗宿主病的6个月死亡率为73%。败血症是最常见的死亡原因(60%)。肠杆菌血症、侵袭性曲霉菌病和播散性念珠菌感染是常见的报告。受者年龄超过50岁是移植后移植物抗宿主病的危险因素。在报告的美国移植物抗宿主病(GVHD)病例中，与所有联合国操作系统数据库LT病例相比，肝细胞癌(肝细胞癌)比例过高，而慢性丙型肝炎比例较低。肝移植后移植物抗宿主病(GVHD)单用大剂量激素治疗死亡率为84%，大剂量钙调神经磷酸酶抑制剂(CNI)治疗死亡率为75%~100%，IL-2拮抗剂治疗死亡率为55%。在使用CD2阻滞剂阿法塞特或肿瘤坏死因子-α(肿瘤坏死因子-α)拮抗剂的小病例系列中，死亡率为25%。年龄超过50岁和肝细胞癌似乎是移植物抗宿主病的危险因素。丙型肝炎可能具有保护性作用。大剂量激素和CNI治疗肝移植后移植物抗宿主病无效。CD2受体阻滞剂和肿瘤坏死因子-α拮抗剂似乎很有希望。我们提出了一种诊断算法来帮助临床医生处理成人肝移植术后移植物抗宿主病。
Graft-versus-host-disease (GVHD) after liver transplantation (LT) is a deadly complication with very limited data on risk factors, diagnosis and management. We report a case series and a comprehensive review of the literature. Data was systematically extracted from reports of GVHD after LT, and from the United Network for Organ Sharing (UNOS) database. Group comparisons were performed. 156 adult patients with GVHD after LT have been reported. Median time to GVHD onset was 28 days. Clinical features were skin rash (92%), pancytopenia (78%) and diarrhea (65%). 6-month mortality with GVHD after LT was 73%. Sepsis was the most common cause of death (60%). Enterobacter bacteremia, invasive aspergillosis and disseminated Candida infections were frequently reported. Recipient age over 50-years is a risk factor for GVHD after LT. Hepatocellular carcinoma (HCC) was over-represented, while chronic hepatitis C was under-represented, in reported United States GVHD cases relative to all UNOS database LT cases. Mortality rate with treatment of GVHD after LT was 84% with high-dose steroids alone, 75–100% with regimens using dose increases of calcineurin inhibitors (CNI), and 55% with IL-2 antagonists. Mortality was 25% in small case series using the CD2-blocker alefacept or tumor necrosis factor-α (TNF-α) antagonists. Age over 50-years and HCC appear to be risk factors for GVHD. Hepatitis C may be protective. High-dose steroids and CNI are ineffective in the treatment of GVHD after LT. CD2-blockers and TNF-α antagonists appear promising. We propose a diagnostic algorithm to assist clinicians in managing adults with GVHD after LT.