Wednesday, May 22, 2013

GVHD after Kidney transplantation? Can this happen?

GVHD is mainly associated with allogenic hematopoietic stem cell transplantation, and occurs much less frequently after transplantation of immunologically active solid organs such as liver and small intestine. GVHD after solid organ transplantation(SOT) is a very rare and frequently lethal complication caused by the engraftment and proliferation of allograft-associated lymphocytes in the immunosuppressed recipient, with subsequent immune-mediated attack by donor-origin effector cells directed against HLA-disparate host tissues. SOT-GVHD occurs most frequently following small bowel and liver transplantation, followed by lung and kidney transplantation in decreasing order of frequency. Risk factors for SOT-GVHD are the quantity of lymphoid tissue in the donor organ, greater degrees of HLA match between donor and recipient and recipient age over 65 years. Given there are immune system related tissue when one does solid transplants such as small bowel or liver is not uncommon.
80 cases of GVHD after liver transplant were reported in 2008, with published incidence rates of 1-2%.  worldwide. GVHD is the consequence of an immunologic reaction of engrafted lymphoid cells against the tissues of the host. It is known that transient lymphocyte chimerism occurs in recipients of SOT, and in fact it is thought to be necessary for the establishment of organ tolerance; however, lymphocyte chimerism usually rapidly decreases over time so that by the third postoperative week not allowing the risk of GVHD.
Only 4 cases of kidney transplantation associated GVHD ( what I found) have been reported. Typical symptoms and signs of GVHD are skin rash, severe diarrhea, and the elevation of total bilirubin, but these findings were often attributed by drug reactions or infections. These may make the delay of GVHD diagnosis.  The earliest time frame reported is 17 days after transplantation and latest up to 240 days following it.  Majority of those cases presented with diarrhea or rash and 50% mortality.
Specific tests have been used in diagnosis of GVHD. One is detection of macrochimerism which was defined as more than 1% donor nucleated cells in the peripheral blood of recipient, and the other is single-tandem repeat (STR) DNA analysis which quantifies relative amounts of different DNA in a single tissue sample.  A gastrointestinal source based disease usually reveals apoptotic cells in the endoscopy or colonoscopy findings.
A recent article discusses a case report from Korea. The other 3 cases have been from Japan and USA.

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