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Transplant-Related
Complications
Prof. Ilona Hromadníková, Ph.D.
Department of Molecular Biology and Cell Pathology
Third Faculty of Medicine, Charles University in Prague
Graft versus host reaction
• graft versus host disease (GvHD)
• major complication after allogeneic transplantation
• consequence of incomplete match in HLA system or mismatch
in other antigens outside major histocompatibility complex
(miHAg), polymorphisms in genes for cytokines and others
• result of HLA and miHAg antigen recognition in patient by
donor‘s T lymphocytes → leading to tissue damage
• host versus graft reaction = recognition of donor‘s HLA and
miHAg antigens by the patient, often ends with rejection
Circumstances for GvHD development
• graft contains immunocompetent cells, mature T lymphocytes
GvHD correlates with the number of donor‘s T lymphocytes
• recipient expresses tissue antigens which donor doesn‘t have
HLA strongly stimulate allogeneic T lymphocytes
miHAg can induce GvHD even in HLA-identical transplants
• rare development in autologous and syngeneic Tx – recognition of
own antigens as foreign leads to the induction of autoimmune
process
• development after solid organ Tx containing lymphatic tissue
• development after blood transfusion: donor homozygous for one recipient‘s
haplotype recognizes antigens from the other haplotype
Non-HLA immunogenetics and GvHD
• minor histocompatibility antigens
peptides derived from intracellular proteins presented by HLA
- male specific mHAg encoded by Y chromosome complicates HLA-identical Tx in
setting from female to male
- other mHAg expressed on hematopoetic cells (HA-1, HA-2) or other tissues
(H-Y, HA-3), mismatch in HA-1, -2, -4, -5 associated with↑ risk of GvHD
• polymorphisms in genes for cytokines and genes with relation to
immune system
↑ pro-inflammatory cytokine expression (TNF-a, IL-6, IFN-g) – risk of GvHD, antiinflammatory (IL-10, IL-1Ra) – protective effects
• polymorphisms of other genes
polymorphism in vitamin D receptor and estrogen receptor – association with
GvHD development
Polymorphisms in cytokine genes
in regulatory region of the gene → high/low cytokine production
TNFd3
pro-inflammatory function, ↑ TNF-a production
P: ↑ aGvHD risk in HLA identical sibling BMT
TNF receptor
unknown function (TNFRII receptor stimulates T cell proliferation
and alloimmune response)
D: more severe GvHD in MUD HSCT
P: ↑ aGvHD risk in HLA identical sibling BMT
IL-10
anti-inflammatory function, haplotype association with ↓
production
P: ↑ GvHD risk in BMT, P&D: association with aGvHD
IL-6
pro-inflammatory function, allele G associated with↑production
P: ↑ a,cGvHD risk in HLA identical sibling Tx
IFN-g
pro-inflammatory function, lower production in vitro
Intron 1
P: ↑ aGvHD risk in HLA identical sibling Tx
IL-1
pro-inflammatory function, D: ↑ cGvHD risk in HLA identical
IL-1a 889;intron 6 VNTR
sibling Tx
Acute GvHD
• develops usually within 2 – 5 weeks post Tx (until D+100)
• also earlier – hyperacute GvHD, reason is HLA non-identical graft
• in 30-60% cases of HLA identical sibling Tx despite of
immunosuppressive prophylaxis
• depends on number of T lymphocytes in graft, donor
allosensibilization, patient‘s age, conditioning type and prevention
methods of GvHD development
• most frequently involved organs: skin, liver, GIT
frequent involvement of epithelial surfaces: conjunctiva, esophagus
and vagina
aGvHD pathophysiology
• Phase 1: donor T-cell infusion
patient damaged by underlying disease, infection and particularly by the
conditioning regimen → result in activation of host cells: secretion of
proinflammatory cytokines (TNF-a, IL-1) with consequences of increased
expression of adhesion molecules and HLA antigens
• Phase 2: T-cell activation
2a. donor T-cell interaction with host APCs → proliferation, differentiation and
secretion of cytokines (IL-2, IFN-g)
2b.IL-2, IFN-g enhance T-cell expansion, induce CTL and NK cell responses,
activate phagocytes to produce TNF-a and IL-1
2c. TNF-a and IL-1 activate proinflammatory chemokines → thus recruiting
effector cells into target organs
aGvHD pathophysiology
• Phase 3: cellular and inflammatory effector phase
complex cascade of multiple effectors (CTLs, NK cells) and inflammatory
effectors (TNF-a, IL-1), complex inflammatory response
secondary signal for macrophages provided by LPS leaking through
intestinal mucosa damaged during phase 1
result in tissue destruction
Ferrara et al., 1997
Clinical manifestation of aGvHD
• skin involvement
maculo-papular rash, can spread and involve the entire body
surface with desquamation
• GIT involvement
anorexia, nausea, diarrhea, abdominal pain, paralytic ileus
• liver involvement
hyperbilirubinemia, increase of transaminases and alkaline
phosphatase
• infection
severe immunodefficiency – poor resistance against infection
Patient with acute skin GvHD of grade 4 resistant to steroid treatment
a) epidermolysis, at D+2 of Alefacept treatment (inhibits T-cell activation)
b) almost complete epithelialization of the skin, only mild GvHD activity at D+7 of
Alefacept treatment
c) exacerbation at D+9 of Alefacept treatment, including markedly increased solar
erythema d) D+19, complete remission
aGvHD grading system
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•
•
•
results from stages of skin, liver and GIT involvement
usually predicts the clinical course and prognosis
mild form – mild morbidity, almost without mortality
more severe stages – mortality elevation, up to 100%
Grading system of organ involvement for acute GvHD
skin
GIT
liver
rash
diarrhea
bilirubin
% of body surface
in l/24 h
mmol/l
< 25%
0.5 l
12 - 20
1
25 - 50%
1.0 l
20 - 50
2
> 50%
≥ 1.5 l
> 50
3
desquamation
stage
pain, ileus AST, ALT elevation
4
Overall grading system for acute GvHD according to the degree of
individual organ involvement
skin
GIT
liver
grade
1-2
-
-
I
1-3
1
1
II
2-3
2-3
2-3
III
2-4
2-4
2-3
IV
Treatment of aGvHD
• treatment and prophylaxis – immunosuppressives:
corticosteroids
cyclosporine A
anti-thymocyte globulin
monoclonal antibodies (against CD25, IL-2, TNF – combination)
immunotoxins
FK506 (tacrolimus)
thalidomide
UV radiation (photophoresis – extracorporal photochemotherapy)
Treatment of aGvHD
• mild forms (skin rash)
overall treatment is not necessary
local treatment with corticosteroid cremes
• extensive rash, overall symptoms, liver and gut involvement
overall treatment is necessary
high corticosteroid doses (methylprednisolon 1 g/m2/day in 1 or 2 doses) over 3 days
good responders – reducing to a half dose every 3rd day
new intensification treatment in case of progression
more severe forms of GvHD often followed by infection with fever
Treatment of aGvHD
infection – elevation of CRP in bacterial (not in viral and mycotic)
infection
antibiotics (e.g. ceftazidime with aminoglycosides)
no responders to corticoids:
resistant aGvHD with unfavourable prognosis (high mortality)
possible transition to chronic GvHD
treatment with monoclonal antibodies can be effective
low long-term survival (cca 20%)
Treatment of aGvHD
FK506 (tacrolimus)
• blocks T-cell activation
• effective in preventing and treatment of rejection in solid organ Tx
• treatment of aGvHD – significant improvement of skin and gut
symptoms
lower effect on liver GvHD
• extensive nephrotoxicity and neurotoxicity
Chronic GvHD
• result of later phase of allogeneic Tx
• develops newly or after aGvHD (occurence after day 100 post
Tx)
• in 30 – 60% of patients
• risk of development:
incomplete match in HLA antigens
higher patient‘s age
previous aGvHD
donor leukocyte infusion
CMV infection
donor‘s seropositivity for CMV
Early chronic GvHD diagnostics
Examination
physical examination of the skin
skin biopsy
skin biopsy - direct fluorescence
oral biopsy
oral biopsy - direct fluorescence
eye tests
Finding
changes in pigmentation or erythema
necrotic keratinocytes with eozinophilic cytoplasma,
basal cell vacuolization
deposits of IgM or C3 along the dermo-epidermal
junction
mucositis and/or sialadenitis
cytoid bodies, deposits of J chain of immunoglobuline
Schirmer test < 10 mm, epithelial cornea lesis
• small ability of defence against infection
• skin changes - papulo-squamous-like dermatitis with pigmentation defect,
frequent failure in hair and nail growth
• later stages: image similar to sclerodermia, SLE, Sjögren syndrome,
rheumatoid arthritis and primary biliary cirrhosis
• in cca 80% of patients cholestatic hepatopathy
• severe involvement of oral and esophageal mucosa → malnutrition, sicca
syndrome development
Grading system for cGvHD
• Extensive cGvHD
- bioptic demonstration of generalized skin involvement or
- bioptic demonstration of localized skin involvement and/or liver abnormality
due to GvHD
plus some of the other indicator:
a) bioptic demonstration of aggressive liver involvement
b) ocular sicca syndrome (dryness)
c) bioptic demonstration of oral mucosis involvement
d) demonstration of other organs involvement
•
Limited cGvHD
localized skin involvement and/or liver dysfunction due to cGvHD
Treatment of cGvHD
1. corticosteroids (prednisolon 20 – 40 mg/day)
2. cyclosporine A – regular check of blood levels necessary
3. their combination in case of incomplete response
4. thalidomide
sedative with antiinflammatory and immunosuppressive effect
inhibition of TNF-a production, suppressor cell induction
attenuation, constipation, paresthesia
5. irradiation of lymphatic system (TLI)
6. penicillamine
in refractery forms with sclerosing skin involvement, influences fibrotic
changes and collagen deposits
7. FK506
simultaneous usage of cotrimoxazole or pentamidine to prevent pneumocystic
infection
Local treatment of cGvHD
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skin changes – corticoids
eye dryness – artificial tears
limited movement – exercising, physiotherapy
contractures – surgical reparation in stabilized GvHD
refractory chronic skin manifestations – PUVA (psoralen with UV
irradiation - photopheresis – extracorporal photochemotherapy)
Supportive treatment during cGvHD
• Pneumocystis carinii infection prevention – during corticoid
treatment
• hypogamaglobulinemia – treatment with immunoglobulines
• ovarial hormone substitution – especially after TBI and busulphan
• calcium supply – prevention of osteoporosis development
• growth hormone substitution
• sicca syndrome treatment (artificial tears and saliva, bubble gum,
vagina lubricans)
• treatment of liver involvement with ursodeoxycholic acid
• protection against solar radiation - cremes
• rational vaccination
Prognostic factors in cGvHD
Factor
favourable
unfavourable
GvHD range
limited
extensive
patient‘s age
< 20 years
> 20 years
aGvHD grade
0-I
II-IV
de novo
progressive
> 100
< 100
> 100x109/l
< 100x109/l
type of cGvHD during the onset
day of the onset of cGvHD
thrombocyte number
Treatment response after 9 months complete remission no response
Most important prognostic factors:
development from acute GvHD
lichenoid skin changes
bilirubin elevation
persistant thrombocytopenia
negative response to the treatment
with 2 or more risk factors survives cca 20% of patients
GvHD in autologous
and syngeneic Tx
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possible development of GvHD-like syndrome
predominant skin involvement
development most frequently after conditioning with TBI
development probably due to thymus dysfunction
mild manifestation, treatment with corticoids
GvHD prevention
• HLA compatibility
• post-Tx immunosuppression:
glucocorticoids – IL-1 attenuation
methotrexate – inhibition of cell division and clonal expansion of T cells
cyclosporine A – inhibition of IL-2 synthesis, T-cell activation
rapamycin, deoxyspergualin, mizoribin, leflunomid
• T-cell depletion in graft – milder course of GvHD, missing GvL
effect!
• Campath-1 (CDw52) antibodies – T-cell elimination, nonengraftment and risk of relapse
• Tx of separated CD34+ stem cells
• cytokine inhibition
Sinusoidal obstructive syndrome
(Veno-occlusive liver disease)
• toxic damage of sinusoidal endothelia due to conditioning regimen
characterized by:
jaundice, liquid retainment and putting on the weight (edema), usual painful
hepatomegaly
• unknown pathogenesis, hepatocyte involvement probably due to
accumulation of toxic metabolites of certain conditioning regimen
drugs
• usually within 14 days post Tx
• severe cases: SOS with MOF (multiorgan failure) – thrombocytopenia,
pleural effusion, progressive renal, cardiac and pulmonary failure, wooziness,
encephalopathy, coma
• diagnostics – clinical symptoms: bilirubin level, hepatomegaly, weight gain
• differential diagnosis – exclusion: infection, aGvHD, drug toxicity, etc.
Infection
• risk early after Tx, especially in aplastic phase
• microorganisms (MO), by which patient was previously colonized
• prevention by patient isolation
• prevention of granulocytopenic infection with selective suppression
of potencially pathogenic MO → ATB against G- bacteria
antimycotics concurrently
3 days prior starting conditioning regimen untill granulocyte
elevation > 0.5x109/l
• prevention of a-hemolytic streptococcal infection from D+10 - ATB
Early phase of infectious risk
• lasts cca 3 weeks, neutropenia period prior to engraftment
• Damage of innate immunity barriers with conditioning →
development of oropharyngeal mucosa inflammation,
gastroenteritis, pneumonia and dermatitis
• central catheter - source of infection
• transient immune defficiency due to T- and B-cell ablation,
intensification of immunusuppression with GvHD prophylaxis
• neutrophile decline below 0.5x109/l, most severe infection
below 0.1x109/l → GIT mucosa and respiratory tract
involvement, mostly of endogenous origin
sepsis
• local infection rare – without inflammation, missing purulency
Early phase of infectious risk
• after engraftment lower risk of bacterial complications, if
GvHD does not develop
• etiological agents of mycotic infection:
Candida and Aspergillus (Mucoraceae, Fusarin, Cryptococcus,
Coccidia, Histoplasma)
not easy dg. of systemic infection – demonstration of fungal
antigens besides cultivation
• viral infections
herpes simplex virus activation – involvement of
oropharyngeal mucosa, good treatment response
Intermediate phase of infectious risk
• period from engraftment at least to the 3rd – 4th month post Tx
• cell and humoral immunosuppression, absolute number of T cells is
important
• susceptibility to viral and protozoal infection
• frequent mycotic infection – Aspergillus
• good prophylaxis of intersticial pneumonia (Pneumocystis carinii)
• problems with CMV, pneumonia – the most severe form, mortality
cca 85%
primary infection – transfer by CMV pos. donor
reactivation – patient CMV pos. prior to Tx
reinfection – CMV pos. patient infected with another strain
systemic disease, gastroenteritis or hepatitis – good therapy,
diagnostics improvement
• adenoviral pneumonia
Intermediate phase of infectious risk
• HHV6 infection
associated with pneumonia, delayed engraftment, prolonged
thrombocytopenia and encephalitis
detection of HHV6 DNA in blood during the first months after Tx – difficult
to establish its implication in clinical symptoms
qRT-PCR monitoring (not possible by antibody detection)
• EBV associated lymphoproliferative disease
life-threatening complication after Tx
transfer from donor – testing the pair, prophylaxis in patient
activation associated with patient‘s immunosuppression
risk factor: T-cell depletion of the graft
qRT-PCR monitoring (not possible by antibody detection)
Late phase of infectious risk
• from D+100 until the normalization of immune system
• infectious complications↓
• risk factors result from persisting affected humoral and
cellular immunity (normalization within 1 – 2 years post Tx)
• defence against viruses↓
herpes zoster infection – usually mild, can be disseminated
with lethal encephalitis or pneumonia
• during GvHD: Streptococcus pneumoniae, Haemophilus
influenzae infection
long-term reduction of defence ability during cGvHD due to
GvHD itself and immunosuppressive therapy
Prevention and treatment of
infection
Body surface care
antiseptic solutions for wiping, important mouth care (dental treatment
prior to Tx, frequent washing out post Tx)
GIT decontamination
antibiotics against G - bacteria, antimycotics
Lowbacterial diet
water and food sterilization (bread in autoclave), heat-treated foods,
scalable fruits
Isolation of the patient
rooms equipped with HEPA filters
Nursing regimen
staff – hats, mouthpieces, coats, gloves, overshoes
incoming material decontamination
Prevention and treatment of
infection
Surrounding care
washing of areas, floor
Microbial settlement monitoring
bacteriologic examination of stool, urine and all body cavities
Prophylaxis
wide-spectrum antibiotics
Immunotherapy
passive immunotherapy – intravenous imnunoglobulines, hyperimmune
globulines
active immunization with specific vaccines
cytokines like G-CSF, GM-CSF, interleukines, interferon
Re-vaccination post Tx
• immunization with live vaccines is dangerous
post Tx patients are immunocompromised - not earlier than after 2 years,
chronic GvHD contra-indication
• possible to immunize with dead antigens - also in aGvHD, cGvHD
Recommended immunization
First year post Tx
diphtheria, pertussis, tetanus
H.influenzae, hepB, flu, Salk inactivated vaccine (poliomyelitis)
Second year post Tx
measles, mumps, rubella (if there is epidemiologic indication)
Immunization of family members
- within 1st year not with Sabin (attenuated live) vaccine against poliomyelitis
- against measles, mumps and rubella don‘t threaten transplanted patients
Late consequences of Tx
consequence of conditioning regimen or GvHD – appearance even
after several years post Tx
Irradiation
children reduced growth, failure in face structure and teeth creation
(treatment with growth hormone)
growth failures also after usage of Cy/Bu or long corticoid
treatment of cGvHD
later puberty in girls, hormonal treatment
females usually infertile after irradiation, pregnancy rare
males without mature sperms, usually permanent
restoration of spermatogenesis after milder conditioning regimen
radiating nephritis (also Cy, Mel, CsA, ATB participation)
Late consequences of Tx
• thyroid dysfunction after irradiation
• chronic liver involvement in form of chronic GvHD, chronic active
hepatitis and biliary cirrhosis
• cataracts within 6 years after TBI at the dose of 10 Gy and above
• reduced tears creation and eye dryness after irradiation
• respiratory infections (CMV) also after termination of
immunosuppressive therapy, activation of latent infection or
primary infection during supportive treatment with blood
products
• frequent osteoporosis after treatment with corticoids
artificial menopause, cGvHD
• secondary malignant diseases due to chemo/radiotherapy,
immunosuppression or transplant itself (stem cells with
malignant potential)
Late consequences of Tx
• rarely myastenia gravis and polymyositis
• psychological, psycho-social and social problems
anxiety, small self-confidence, fear of relapse, dependence on
medical staff and family, sexual problems, fear of financial
problems due to long-term treatment, etc.
Late consequence monitoring
recommended examinations for physicians outside Tx unit,
long-term patient monitoring post Tx
Recommended examinations
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skin, oral mucosa, teeth, eyes and joints (GvHD symptoms)
weight
overall blood counts
rtg of lungs, lung function
liver and renal function
thyroid gland function (TSH, T3)
FSH, LH, estrogens, growth hormone, testosterone
blood group and antibody titer (after AB0 incompatibile Tx)
myelogram every 2 months, later every 6 – 12 months
gynecologic examination (prescription of hormonal supportive treatment)
eye examination (exclusion of sicca syndrome and cataract development)
in children height and weight compared to standard
psychological consultations
Case report 1
• female, 3 years (dg. ovarian tumor)
• no siblings
• sec. AML M5 diagnosed after anamnesis of hyperleukocytosis (95% of
blasts in PB), anemia, hyperuricemia, neck and mezenterial
lymphadenopathy
• early isolated bone marrow relapse 7 months after start of chemotherapy
AML BFM protocol, further chemotherapy AML REZ protocol – complete
remission
• MUD HSCT (PBSC) in 2nd CR
donor: F/25, 10/10 match
Conditioning regimen
FLAMSA (Amsacrine, Fludara, ARA-C, fractionated TBI, Cyclophosphamide)
GvHD prophylaxis
Cyclosporine A, ATG, mycophenolate mofetil (MMF)
Post Tx course
• D+13 engraftment (granulocytes)
• D+22 thorax rash, spread to neck and face, followed by subfebrilia,
sulkiness, apepsia, mushy smelly stool
• D+28 GvHD grade II (skin 1, GIT 1, liver 0) - corticoids 1 mg/kg
repair, rash regression
• D+42 reduction of corticoids to 0.6 mg/kg
• D+44 discharged from hospital
• D+69 corticoids discontinued
• persisting hematologic remission, complete donor hematopoiesis
Case report 2
• male, 7 years, CMV positive
• HLA non-identical sister
• c-ALL diagnosed after anamnesis of febrile infection with hemorrhagic
diathesis, hepatosplenomegalia, hyperleukocytosis
• chemotherapy: good response
• early isolated bone marrow relapse (21.5 months from diagnosis) →
combined chemotherapy, end of chemotherapy followed by aplasia,
hyperbilirubinemia
• MUD HSCT (BM) in 2nd CR
donor: M/28, 10/10 match
Conditioning regimen
fractionated TBI, etoposide
GvHD prophylaxis
cyclosporine A, ATG, methotrexate
Post Tx course
• after Tx severe mucositis grade III
• D+10 veno-occlusive disease after anamnesis of interstitial liquid,
hyperbilirubinemia, weight gain, refractory thrombocytopenia,
hepatomegalia, ascites
• D+21 autologous hematopoiesis 1%
• D+23 engraftment (leukocytes)
• D+28 complete donor hematopoiesis
• D+48 CMV re-activation
• D+57 discharged from hospital
• persisting hematologic remission, complete donor hematopoiesis –
intermittently autologous to 1%