title: Liver transplant-associated graft-versus-host disease.
abstract: BACKGROUND
  Graft-versus-host disease (GVHD) is an important, underdiagnosed cause of mortality associated with liver transplantation. We identified 12 cases of GVHD among 1,082 liver transplantations performed in patients at our institution between 1991 and 1998. Patients typically developed fever, skin rash, diarrhea, or pancytopenia within 2 to 6 weeks after their transplant. Treatment generally involved increased immune suppression and hematopoietic cytokines (granulocyte colony stimulating factor, granulocyte monocyte colony stimulating factor); however, all but one patient died, most often from sepsis. Early in its course, GVHD was difficult to distinguish from cytomegalovirus disease or drug reactions. The diagnosis was confirmed by demonstration of substantial donor lymphoid chimerism.
  
  
  METHODS
  To identify risk factors for severe GVHD, a retrospective analysis was performed comparing index cases with the rest of the cases in our institutional experience.
  
  
  RESULTS
  Closely matched human leukocyte antigen recipients, those older than 65 years, and recipients with donors more than 40 years younger were at higher risk for GVHD. One case occurred in a patient with a congenital immunodeficiency.
  
  
  CONCLUSIONS
  Liver transplant-associated GVHD is a progressive and fatal disease. Future approaches should focus on prevention and might include avoidance of closely matched human leukocyte antigen donors, treatment of the donor to reduce the number of lymphocytes, or reduction of immunosuppression in the early posttransplant period.
authors.affiliation: Transplant Immunology Laboratory, Baylor University Medical Center, Dallas, TX, USA. dsmith@baylorhealth.edu
authors.forename: Douglas M
authors.initials: DM
authors.lastname: Smith
authors.forename: Edward
authors.initials: E
authors.lastname: Agura
authors.forename: George
authors.initials: G
authors.lastname: Netto
authors.forename: Robert
authors.initials: R
authors.lastname: Collins
authors.forename: Marlon
authors.initials: M
authors.lastname: Levy
authors.forename: Robert
authors.initials: R
authors.lastname: Goldstein
authors.forename: Laura
authors.initials: L
authors.lastname: Christensen
authors.forename: Judy
authors.initials: J
authors.lastname: Baker
authors.forename: Basel
authors.initials: B
authors.lastname: Altrabulsi
authors.forename: Lori
authors.initials: L
authors.lastname: Osowski
authors.forename: Jeff
authors.initials: J
authors.lastname: McCormack
authors.forename: Lisa
authors.initials: L
authors.lastname: Fichtel
authors.forename: D Brian
authors.initials: DB
authors.lastname: Dawson
authors.forename: Rana
authors.initials: R
authors.lastname: Domiati-Saad
authors.forename: Marvin
authors.initials: M
authors.lastname: Stone
authors.forename: Goran
authors.initials: G
authors.lastname: Klintmalm
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D002648:Child; D002675:Child, Preschool; D005260:Female; D006086:Graft vs Host Disease / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D006650:Histocompatibility Testing; D006801:Humans; D007153:Immunologic Deficiency Syndromes / Q000151:congenital; D016031:Liver Transplantation / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors