From the UOC Anesthesia and Intensive Care Unit, Department of Medicine-DIMED, Padua Hospital, Padua, Italy.
Exp Clin Transplant. 2020 Feb;18(1):123-127. doi: 10.6002/ect.2017.0231. Epub 2018 Apr 4.
Graft-versus-host-disease after orthotopic liver transplant is a rare and life-threatening complication. The diagnosis is challenging and usually confirmed by chimerism and skin biopsies. The most common cause of death is sepsis (60%), and broad-spectrum antibiotics and antifungal prophylaxis are strongly recommended. We present a case of a 61-year-old man with hepatocellular carcinoma and a previous history of metabolic and alcoholic cirrhosis who underwent orthotopic liver transplant. The immunosuppression regimen consisted of corticosteroids, calcineurin inhibitor, and mammalian target of rapamycin complex 1 inhibitor. Nine days after surgery, the patient developed leukopenia and skin rash. After confirmation of graft-versus-host disease by chimerism and skin biopsy, etanercept, a novel anti-tumor necrosis factor-alpha drug used for patients with hematologic and rheumatologic disease, was administrated. Unfortunately, no clinical improvements or bone marrow recovery were noted, and the patient had subsequent fatal sepsis due to Enterococcus faecium, Aspergillus fumigatus, and viral superinfection. There are no US Food and Drug Administration-approved treatments for graft-versus-host disease after orthotopic liver transplant. The main risk factors are recipients > 50 years old, patients with glucose intolerance, patients transplanted due to hepatocellular carcinoma, donor-recipient age difference of > 20 years, and any HLA-class I match. In accordance with the literature, we suggest early use of broad-spectrum antibiotics and antifungal drugs during etanercept treatment. In addition, because of substantially higher risk for severe sepsis, we strongly recommend adding an antiviral prophylaxis to prevent Cytomegalovirus reactivation or unexpected superinfection.
肝移植后移植物抗宿主病是一种罕见且危及生命的并发症。诊断具有挑战性，通常通过嵌合状态和皮肤活检来确认。最常见的死亡原因是脓毒症（60%），强烈推荐使用广谱抗生素和抗真菌预防。我们报告了 1 例 61 岁男性，患有肝细胞癌和既往代谢性和酒精性肝硬化病史，接受了原位肝移植。免疫抑制方案包括皮质类固醇、钙调磷酸酶抑制剂和哺乳动物雷帕霉素靶蛋白 1 抑制剂。术后 9 天，患者出现白细胞减少和皮疹。在通过嵌合状态和皮肤活检确认移植物抗宿主病后，使用依那西普（一种新型用于血液和风湿性疾病患者的抗肿瘤坏死因子-α药物）进行治疗。不幸的是，没有观察到临床改善或骨髓恢复，随后由于粪肠球菌、烟曲霉和病毒合并感染导致患者发生致命性脓毒症。目前尚无美国食品和药物管理局批准的治疗肝移植后移植物抗宿主病的方法。主要的风险因素包括受体年龄>50 岁、葡萄糖不耐受的患者、因肝细胞癌而接受移植的患者、供体与受体年龄差>20 岁以及任何 HLA-I 类匹配。根据文献，我们建议在依那西普治疗期间早期使用广谱抗生素和抗真菌药物。此外，由于严重脓毒症的风险显著增加，我们强烈建议添加抗病毒预防措施以预防巨细胞病毒再激活或意外的合并感染。
