From the Research
Graft-versus-host disease (GVHD) after liver transplantation is a rare but potentially fatal complication with a mortality rate of around 85%. The incidence of GVHD post solid liver organ transplant is estimated to be around 0.1-2% in adult recipients 1. It occurs when immunocompetent donor lymphocytes from the transplanted liver attack the recipient's tissues. Initial signs typically appear 2-6 weeks post-transplant and include:
- Fever
- Skin rash (often starting on palms and soles before becoming generalized and maculopapular)
- Diarrhea
- Pancytopenia
Diagnosis requires a high index of suspicion and is confirmed through skin or intestinal biopsies showing characteristic histological features, along with chimerism studies demonstrating donor lymphocyte presence in recipient blood or tissues.
Management of GVHD
Management begins with high-dose steroids (methylprednisolone 2-10 mg/kg/day) as first-line therapy. For steroid-resistant cases, additional immunosuppressive agents are employed, including:
- Antithymocyte globulin (1.5 mg/kg/day for 5-10 days)
- Tacrolimus adjustment
- Mycophenolate mofetil (1-2 g/day)
- Extracorporeal photopheresis
Supportive care is crucial and includes infection prophylaxis with broad-spectrum antibiotics, antifungals, and antivirals, as well as nutritional support and blood product transfusions as needed. Early recognition and aggressive treatment are essential as mortality rates remain high despite intervention, with death usually resulting from infections or multi-organ failure 1. The fundamental mechanism involves donor T-cells recognizing recipient HLA antigens as foreign, triggering an immune response against the recipient's skin, gastrointestinal tract, and bone marrow.