Transplant-Related Complications

Prof. Ilona Hromadníková, Ph.D.

Department of Molecular Biology and Cell PathologyThird Faculty of Medicine, Charles University in Prague

Graft versus host reactionGraft 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 Circumstances forfor GvHD development GvHD development

• graft contains immunocompetent cells, mature T lymphocytesGvHD correlates with the number of donor‘s T lymphocytes

• recipient expresses tissue antigens which donor doesn‘t haveHLA strongly stimulate allogeneic T lymphocytesmiHAg 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-, IL-6, IFN-) – risk of GvHD, anti-inflammatory (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 genesin regulatory region of the gene → high/low cytokine production

TNFd3 pro-inflammatory function, ↑ TNF-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 HSCTP: ↑ aGvHD risk in HLA identical sibling BMT

IL-10 anti-inflammatory function, haplotype association with ↓ productionP: ↑ GvHD risk in BMT, P&D: association with aGvHD

IL-6 pro-inflammatory function, allele G associated with↑productionP: ↑ a,cGvHD risk in HLA identical sibling Tx

IFN- pro-inflammatory function, lower production in vitroIntron 1 P: ↑ aGvHD risk in HLA identical sibling TxIL-1 pro-inflammatory function, D: ↑ cGvHD risk in HLA identicalIL-1 889;intron 6 VNTR sibling Tx

Acute GvHDAcute 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, GITfrequent involvement of epithelial surfaces: conjunctiva, esophagus and vagina

aGvHD pathophysiologyaGvHD 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-, 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-)

2b.IL-2, IFN- enhance T-cell expansion, induce CTL and NK cell responses, activate phagocytes to produce TNF- and IL-1

2c. TNF- and IL-1 activate proinflammatory chemokines → thus recruiting effector cells into target organs

aGvHD pathophysiologyaGvHD pathophysiology• Phase 3: cellular and inflammatory effector phase

complex cascade of multiple effectors (CTLs, NK cells) and inflammatory effectors (TNF-, IL-1), complex inflammatory responsesecondary signal for macrophages provided by LPS leaking through intestinal mucosa damaged during phase 1result in tissue destruction

Ferrara et al., 1997

Clinical manifestation of aGvHDClinical manifestation of aGvHD

• skin involvementmaculo-papular rash, can spread and involve the entire body surface with desquamation

• GIT involvement anorexia, nausea, diarrhea, abdominal pain, paralytic ileus

• liver involvementhyperbilirubinemia, increase of transaminases and alkaline phosphatase

• infectionsevere 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 treatmentc) exacerbation at D+9 of Alefacept treatment, including markedly increased solar erythema d) D+19, complete remission

aGvHD grading systemaGvHD grading system

• 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%

skin GIT liver stage

rash diarrhea bilirubin

% of body surface in l/24 h mol/l

< 25% 0.5 l 12 - 20 1

25 - 50% 1.0 l 20 - 50 2

> 50% ≥ 1.5 l > 50 3

desquamation pain, ileus AST, ALT elevation 4

Grading system of organ involvement for acute GvHD

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

Overall grading system for acute GvHD according to the degree of individual organ involvement

Treatment of aGvHDTreatment of aGvHD

• treatment and prophylaxis – immunosuppressives:

corticosteroidscyclosporine Aanti-thymocyte globulinmonoclonal antibodies (against CD25, IL-2, TNF – combination)immunotoxinsFK506 (tacrolimus)thalidomideUV radiation (photophoresis – extracorporal photochemotherapy)

• mild forms (skin rash)overall treatment is not necessarylocal 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 aGvHDTreatment of aGvHD

infection – elevation of CRP in bacterial (not in viral and mycotic) infectionantibiotics (e.g. ceftazidime with aminoglycosides)

no responders to corticoids:resistant aGvHD with unfavourable prognosis (high mortality)possible transition to chronic GvHDtreatment with monoclonal antibodies can be effective low long-term survival (cca 20%)

Treatment of aGvHDTreatment 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

Treatment of aGvHDTreatment of aGvHD

Chronic GvHDChronic 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 antigenshigher patient‘s ageprevious aGvHDdonor leukocyte infusionCMV infectiondonor‘s seropositivity for CMV

Early chronic GvHD diagnosticsEarly chronic GvHD diagnostics

• 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

Examination Finding physical examination of the skin changes in pigmentation or erythema

skin biopsynecrotic keratinocytes with eozinophilic cytoplasma, basal cell vacuolization

skin biopsy - direct fluorescencedeposits of IgM or C3 along the dermo-epidermal junction

oral biopsy mucositis and/or sialadenitisoral biopsy - direct fluorescence cytoid bodies, deposits of J chain of immunoglobulineeye tests Schirmer test < 10 mm, epithelial cornea lesis

Grading system for cGvHDGrading system for cGvHD

• Extensive cGvHD

- bioptic demonstration of generalized skin involvement or- bioptic demonstration of localized skin involvement and/or liver

abnormality due to GvHDplus some of the other indicator:

a) bioptic demonstration of aggressive liver involvementb) ocular sicca syndrome (dryness)c) bioptic demonstration of oral mucosis involvementd) demonstration of other organs involvement

• Limited cGvHD

localized skin involvement and/or liver dysfunction due to cGvHD

Treatment of cGvHDTreatment of cGvHD1. corticosteroids (prednisolon 20 – 40 mg/day)2. cyclosporine A – regular check of blood levels necessary

3. their combination in case of incomplete response4. thalidomide

sedative with antiinflammatory and immunosuppressive effectinhibition of TNF-production, suppressor cell inductionattenuation, constipation, paresthesia

5. irradiation of lymphatic system (TLI)6. penicillamine

in refractery forms with sclerosing skin involvement, influences fibrotic changes and collagen deposits

7. FK506simultaneous usage of cotrimoxazole or pentamidine to prevent pneumocystic infection

Local treatment of cGvHDLocal treatment of cGvHD• 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 cGvHDSupportive 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 cGvHDPrognostic factors in cGvHDFactor favourable unfavourable

GvHD range limited extensivepatient‘s age < 20 years > 20 yearsaGvHD grade 0-I II-IVtype of cGvHD during the onset de novo progressiveday of the onset of cGvHD > 100 < 100thrombocyte number > 100x109/l < 100x109/lTreatment response after 9 months complete remission no response

Most important prognostic factors:development from acute GvHDlichenoid skin changesbilirubin elevationpersistant thrombocytopenianegative response to the treatment

with 2 or more risk factors survives cca 20% of patients

GvHD in autologousGvHD in autologousand syngeneic Txand syngeneic Tx

• 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 preventionGvHD prevention• HLA compatibility• post-Tx immunosuppression:

glucocorticoids – IL-1 attenuationmethotrexate – inhibition of cell division and clonal expansion of T cellscyclosporine A – inhibition of IL-2 synthesis, T-cell activationrapamycin, deoxyspergualin, mizoribin, leflunomid

• T-cell depletion in graft – milder course of GvHD, missing GvL effect!

• Campath-1 (CDw52) antibodies – T-cell elimination, non-engraftment 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 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- bacteriaantimycotics concurrently3 days prior starting conditioning regimen untill granulocyte elevation > 0.5x109/l

• prevention of -hemolytic streptococcal infection from D+10 - ATB

Early phase of infectious riskEarly 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 originsepsis

• local infection rare – without inflammation, missing purulency

• 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 infectionsherpes simplex virus activation – involvement of oropharyngeal mucosa, good treatment response

Early phase of infectious riskEarly phase of infectious risk

Intermediate phase of infectious riskIntermediate 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. donorreactivation – patient CMV pos. prior to Txreinfection – CMV pos. patient infected with another strain

systemic disease, gastroenteritis or hepatitis – good therapy, diagnostics improvement

• adenoviral pneumonia

Intermediate phase of infectious riskIntermediate phase of infectious risk• HHV6 infection

associated with pneumonia, delayed engraftment, prolonged thrombocytopenia and encephalitisdetection of HHV6 DNA in blood during the first months after Tx – difficult to establish its implication in clinical symptomsqRT-PCR monitoring (not possible by antibody detection)

• EBV associated lymphoproliferative diseaselife-threatening complication after Txtransfer from donor – testing the pair, prophylaxis in patientactivation associated with patient‘s immunosuppressionrisk factor: T-cell depletion of the graftqRT-PCR monitoring (not possible by antibody detection)

Late phase of infectious riskLate 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 Prevention and treatment of infectioninfection

Body surface careantiseptic solutions for wiping, important mouth care (dental treatment prior to Tx, frequent washing out post Tx)

GIT decontaminationantibiotics against G - bacteria, antimycotics

Lowbacterial dietwater and food sterilization (bread in autoclave), heat-treated foods, scalable fruits

Isolation of the patientrooms equipped with HEPA filters

Nursing regimenstaff – hats, mouthpieces, coats, gloves, overshoesincoming material decontamination

Prevention and treatment of Prevention and treatment of infectioninfection

Surrounding carewashing of areas, floor

Microbial settlement monitoringbacteriologic examination of stool, urine and all body cavities

Prophylaxiswide-spectrum antibiotics

Immunotherapy passive immunotherapy – intravenous imnunoglobulines, hyperimmune globulinesactive immunization with specific vaccinescytokines 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 immunizationFirst year post Txdiphtheria, pertussis, tetanusH.influenzae, hepB, flu, Salk inactivated vaccine (poliomyelitis)

Second year post Txmeasles, 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 Txconsequence of conditioning regimen or GvHD – appearance even

after several years post Tx

Irradiationchildren 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 cGvHDlater puberty in girls, hormonal treatment

females usually infertile after irradiation, pregnancy raremales without mature sperms, usually permanent

restoration of spermatogenesis after milder conditioning regimenradiating 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 corticoidsartificial 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 problemsanxiety, 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 monitoringrecommended examinations for physicians outside Tx unit, long-term patient monitoring post Tx

Recommended examinations• 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 CRdonor: F/25, 10/10 match

Conditioning regimenFLAMSA (Amsacrine, Fludara, ARA-C, fractionated TBI, Cyclophosphamide)GvHD prophylaxisCyclosporine 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 CRdonor: M/28, 10/10 match

Conditioning regimenfractionated TBI, etoposideGvHD prophylaxiscyclosporine 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%